Healthcare Provider Details

I. General information

NPI: 1851380703
Provider Name (Legal Business Name): JESTINE A GAHAGAN X RAY TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E PINE ST
TULSA OK
74106-4849
US

IV. Provider business mailing address

603 E PINE ST
TULSA OK
74106-4849
US

V. Phone/Fax

Practice location:
  • Phone: 918-295-6137
  • Fax: 918-582-0529
Mailing address:
  • Phone: 918-295-6137
  • Fax: 918-582-0529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number259819
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: