Healthcare Provider Details

I. General information

NPI: 1598089955
Provider Name (Legal Business Name): MEREDITH L. MOGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2010
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713B S PEORIA AVE
TULSA OK
74120-6801
US

IV. Provider business mailing address

1713B S PEORIA AVE
TULSA OK
74120-6801
US

V. Phone/Fax

Practice location:
  • Phone: 918-622-2500
  • Fax: 405-789-6734
Mailing address:
  • Phone: 918-622-2500
  • Fax: 405-419-7745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1884
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: