Healthcare Provider Details

I. General information

NPI: 1285268771
Provider Name (Legal Business Name): AUSTIN WILLIAM BRASHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E MAIN ST
TISHOMINGO OK
73460-2409
US

IV. Provider business mailing address

1705 GEETA RD
EDMOND OK
73003-3707
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2396
  • Fax:
Mailing address:
  • Phone: 405-474-6361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7313
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: