Healthcare Provider Details

I. General information

NPI: 1306203815
Provider Name (Legal Business Name): ROBERT MIXON RPA/R.R.A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S UTICA AVE
TULSA OK
74104-6520
US

IV. Provider business mailing address

PO BOX 4939
TULSA OK
74159-0939
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-3131
  • Fax:
Mailing address:
  • Phone: 918-743-8943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number5
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: