Healthcare Provider Details

I. General information

NPI: 1952384232
Provider Name (Legal Business Name): TOM J GRESHAM P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 S DARLINGTON AVE STE 700
TULSA OK
74135-6348
US

IV. Provider business mailing address

PO BOX 4939
TULSA OK
74159-0939
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-8943
  • Fax: 918-743-9058
Mailing address:
  • Phone: 918-743-8943
  • Fax: 918-743-9058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number765
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: