Healthcare Provider Details

I. General information

NPI: 1720514219
Provider Name (Legal Business Name): KARINA MARIA JOHANNES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 TERRACE DR
TULSA OK
74104
US

IV. Provider business mailing address

1430 TERRACE DR
TULSA OK
74104-4626
US

V. Phone/Fax

Practice location:
  • Phone: 918-748-8024
  • Fax: 918-748-8249
Mailing address:
  • Phone: 918-748-8024
  • Fax: 918-748-8249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 2783
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: