Healthcare Provider Details

I. General information

NPI: 1104670884
Provider Name (Legal Business Name): ADVANCED FAMILY CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 05/18/2024
Certification Date: 05/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9320 S MINGO RD
TULSA OK
74133-5710
US

IV. Provider business mailing address

9320 S MINGO RD
TULSA OK
74133-5710
US

V. Phone/Fax

Practice location:
  • Phone: 918-901-9701
  • Fax: 918-901-9702
Mailing address:
  • Phone: 918-921-5701
  • Fax: 918-901-9702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KENNETH REED
Title or Position: OWNER
Credential: MD
Phone: 918-921-5701