Healthcare Provider Details

I. General information

NPI: 1023898616
Provider Name (Legal Business Name): BLAYNE BORDWINE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

12721 NW 137TH ST
PIEDMONT OK
73078-8149
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License Number215424
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number215424
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: