Healthcare Provider Details

I. General information

NPI: 1992963383
Provider Name (Legal Business Name): WARREN CLINIC BROKEN ARROW PEDIATRICS SOONERCARE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 S YALE AVE STE 1400
TULSA OK
74136-3310
US

IV. Provider business mailing address

2950 S ELM PL STE 430
BROKEN ARROW OK
74012-7877
US

V. Phone/Fax

Practice location:
  • Phone: 918-488-6001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHY MASON
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 918-488-6687