Healthcare Provider Details

I. General information

NPI: 1528564929
Provider Name (Legal Business Name): ST. JOHN PHYSICIANS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717B S UTICA AVE STE 205
TULSA OK
74104-5332
US

IV. Provider business mailing address

1923 S UTICA AVE # DT1000
TULSA OK
74104-6520
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-2444
  • Fax: 918-744-2483
Mailing address:
  • Phone: 918-744-2630
  • Fax: 918-744-2946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: JAMES BRYAN FISSEL
Title or Position: DIRECTOR CHIEF FINANCIAL OFFICER
Credential:
Phone: 918-748-7617