Healthcare Provider Details

I. General information

NPI: 1164934154
Provider Name (Legal Business Name): ROY SANDERSON NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

7708 S SHERWOOD AVE
OKLAHOMA CITY OK
73159-4634
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-1000
  • Fax:
Mailing address:
  • Phone: 405-694-3363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number58325
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: