Healthcare Provider Details

I. General information

NPI: 1902123862
Provider Name (Legal Business Name): HUNTER TY HULL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 E CEDAR RIDGE RD
TISHOMINGO OK
73460-4019
US

IV. Provider business mailing address

2205 E CEDAR RIDGE RD
TISHOMINGO OK
73460-4019
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-5071
  • Fax:
Mailing address:
  • Phone: 580-371-5071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: