Healthcare Provider Details

I. General information

NPI: 1902106586
Provider Name (Legal Business Name): SURGICAL SERVICES OF OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 10/28/2010
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: 405-601-0954
  • Fax: 405-601-3750
Mailing address:
  • Phone: 405-601-0954
  • Fax: 405-601-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA03727
License Number StateOK

VIII. Authorized Official

Name: CHAD L. NICHOLS
Title or Position: VICE PRESIDENT
Credential: P.A.
Phone: 405-601-0954