Healthcare Provider Details

I. General information

NPI: 1710699715
Provider Name (Legal Business Name): CASSIE RENEE BRIBIESCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

1100 CROMWELL AVE
MUSKOGEE OK
74403-2123
US

V. Phone/Fax

Practice location:
  • Phone: 539-302-4210
  • Fax:
Mailing address:
  • Phone: 918-348-2233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: