Healthcare Provider Details

I. General information

NPI: 1619750015
Provider Name (Legal Business Name): PETER ALLAN IPPOLITI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 S UTICA AVE
TULSA OK
74104-4012
US

IV. Provider business mailing address

5801 E 41ST ST STE 900
TULSA OK
74135-5631
US

V. Phone/Fax

Practice location:
  • Phone: 405-880-8046
  • Fax:
Mailing address:
  • Phone: 918-934-8347
  • Fax: 918-743-8552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5760
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: