Healthcare Provider Details

I. General information

NPI: 1689395402
Provider Name (Legal Business Name): SOULIYA SCOTT CHAN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

4206 NE 33RD ST
OKLAHOMA CITY OK
73121-5629
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-1000
  • Fax:
Mailing address:
  • Phone: 405-306-4978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR0067678
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: