Healthcare Provider Details

I. General information

NPI: 1932595576
Provider Name (Legal Business Name): KAITLIN PAIGE DOMEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2015
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 E 91ST ST STE 200
TULSA OK
74137-2806
US

IV. Provider business mailing address

6600 S YALE AVE STE 1400
TULSA OK
74136-3331
US

V. Phone/Fax

Practice location:
  • Phone: 918-794-4788
  • Fax: 918-794-4789
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number38360
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: