Healthcare Provider Details

I. General information

NPI: 1487817375
Provider Name (Legal Business Name): BRAD ALAN LISTON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 N 14TH ST STE 204
PONCA CITY OK
74601-2039
US

IV. Provider business mailing address

1908 N 14TH ST STE 204
PONCA CITY OK
74601-2039
US

V. Phone/Fax

Practice location:
  • Phone: 580-763-5900
  • Fax: 580-763-5901
Mailing address:
  • Phone: 580-763-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4659
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: