Healthcare Provider Details

I. General information

NPI: 1730389735
Provider Name (Legal Business Name): PRAGUE MEDICAL ALLIANCE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 KLABZUBA
PRAGUE OK
74864
US

IV. Provider business mailing address

PO BOX 842
PRAGUE OK
74864-0842
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-2295
  • Fax: 405-567-4905
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. KERRY PLUM
Title or Position: OFFICE MANAGER
Credential:
Phone: 405-567-2295