Healthcare Provider Details

I. General information

NPI: 1609833078
Provider Name (Legal Business Name): MARK R. GILLEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 S YALE AVE
TULSA OK
74136-1930
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 918-495-2600
  • Fax: 918-497-3007
Mailing address:
  • Phone: 918-488-6001
  • Fax: 918-488-6010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1178
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: