Healthcare Provider Details

I. General information

NPI: 1417952904
Provider Name (Legal Business Name): BRIAN TRAVIS PENDARVIS ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SOUTH MAIN STREET
NOBLE OK
73068
US

IV. Provider business mailing address

205 SOUTH MAIN STREET PO BOX 2096
NOBLE OK
73068
US

V. Phone/Fax

Practice location:
  • Phone: 405-872-5403
  • Fax: 405-872-5407
Mailing address:
  • Phone: 405-872-5403
  • Fax: 405-872-5407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0067224
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: