Healthcare Provider Details

I. General information

NPI: 1477809648
Provider Name (Legal Business Name): WESLEY A. LOWER CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 N MAY AVE SUITE C
OKLAHOMA CITY OK
73112-6641
US

IV. Provider business mailing address

3601 N MAY AVE SUITE C
OKLAHOMA CITY OK
73112-6641
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-5613
  • Fax: 405-601-3750
Mailing address:
  • Phone: 405-604-5613
  • Fax: 405-601-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number21
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: