Healthcare Provider Details

I. General information

NPI: 1164829057
Provider Name (Legal Business Name): SEAN ANDERSON AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 S ORCHARD ST
STILLWATER OK
74074-4218
US

IV. Provider business mailing address

1701 RENAISSANCE BLVD
EDMOND OK
73013-3086
US

V. Phone/Fax

Practice location:
  • Phone: 405-780-6650
  • Fax: 405-844-0562
Mailing address:
  • Phone: 405-844-4978
  • Fax: 405-844-0562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number19170
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPN19170
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN19170
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: