Healthcare Provider Details

I. General information

NPI: 1134105257
Provider Name (Legal Business Name): PAUL RYAN STAFFORD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 E 21ST ST SUITE 320
TULSA OK
74114-1722
US

IV. Provider business mailing address

2424 E 21ST ST SUITE 320
TULSA OK
74114-1722
US

V. Phone/Fax

Practice location:
  • Phone: 918-392-4547
  • Fax: 918-392-4555
Mailing address:
  • Phone: 918-392-4547
  • Fax: 918-392-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number24970
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: