Healthcare Provider Details

I. General information

NPI: 1922334903
Provider Name (Legal Business Name): CANDICE JOY BURKART P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

13499 N 390 RD
HULBERT OK
74441-5621
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax:
Mailing address:
  • Phone: 918-931-0141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1851
License Number StateOK

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: