Healthcare Provider Details

I. General information

NPI: 1225772502
Provider Name (Legal Business Name): BOMAONYE TIENABESO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2022
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 S WALNUT ST
STILLWATER OK
74074-4222
US

IV. Provider business mailing address

1316 NW 170TH ST
EDMOND OK
73012-7410
US

V. Phone/Fax

Practice location:
  • Phone: 405-533-5058
  • Fax:
Mailing address:
  • Phone: 405-476-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number39686
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: