Healthcare Provider Details

I. General information

NPI: 1093833220
Provider Name (Legal Business Name): MICHAEL CLARK FRETER S.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 E 13TH ST SUITE #400
TULSA OK
74104-4419
US

IV. Provider business mailing address

11251 WESTFALL RD
SKIATOOK OK
74070-5289
US

V. Phone/Fax

Practice location:
  • Phone: 918-599-8200
  • Fax: 918-583-4678
Mailing address:
  • Phone: 918-396-2468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberNONE
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: