Healthcare Provider Details

I. General information

NPI: 1821355694
Provider Name (Legal Business Name): RANDY SCOTT JORDAN RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 S GARNETT RD
TULSA OK
74146-5229
US

IV. Provider business mailing address

3227 S 16TH ST
BROKEN ARROW OK
74012-1801
US

V. Phone/Fax

Practice location:
  • Phone: 918-728-6194
  • Fax: 918-664-0267
Mailing address:
  • Phone: 918-728-6194
  • Fax: 918-664-0267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number279995
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: