Healthcare Provider Details

I. General information

NPI: 1134800964
Provider Name (Legal Business Name): DONAVON BALDRIDGE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

204 TOMMYE LN
TAHLEQUAH OK
74464-4174
US

V. Phone/Fax

Practice location:
  • Phone: 539-234-1000
  • Fax:
Mailing address:
  • Phone: 918-774-7326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201015
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201015
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201015
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: