Healthcare Provider Details

I. General information

NPI: 1245580489
Provider Name (Legal Business Name): CRYSTAL LEA COLLINS RPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S GARNETT RD STE 919
TULSA OK
74146-5214
US

IV. Provider business mailing address

3441 S 148TH EAST PL
TULSA OK
74134-4805
US

V. Phone/Fax

Practice location:
  • Phone: 918-728-6194
  • Fax: 918-664-2521
Mailing address:
  • Phone: 918-519-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: