Healthcare Provider Details

I. General information

NPI: 1346083623
Provider Name (Legal Business Name): ALEXIS DITREN SANTOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19500 E ROSS ST
TAHLEQUAH OK
74464-0515
US

IV. Provider business mailing address

717 N VINITA AVE
TAHLEQUAH OK
74464-2232
US

V. Phone/Fax

Practice location:
  • Phone: 918-525-6191
  • Fax:
Mailing address:
  • Phone: 917-979-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
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: