Healthcare Provider Details

I. General information

NPI: 1124612221
Provider Name (Legal Business Name): PREMIER PROVIDER HEALTH OKLAHOMA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4012
US

IV. Provider business mailing address

1 CHISHOLM TRAIL RD STE 5200
ROUND ROCK TX
78681-5090
US

V. Phone/Fax

Practice location:
  • Phone: 512-202-3830
  • Fax: 512-354-1106
Mailing address:
  • Phone: 512-202-3830
  • Fax: 512-354-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: HAN PHAM HULEN
Title or Position: PRESIDENT AND OWNER
Credential: MD
Phone: 214-274-1507