Healthcare Provider Details

I. General information

NPI: 1043430671
Provider Name (Legal Business Name): KEITH JO KANTNER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE XAVIER BUILDING
TULSA OK
74136-1902
US

IV. Provider business mailing address

4505 E 103RD ST
TULSA OK
74137-5946
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2458
  • Fax: 918-494-2475
Mailing address:
  • Phone: 918-298-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR0039430
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: