Healthcare Provider Details

I. General information

NPI: 1336444694
Provider Name (Legal Business Name): CHAD RYAN MCIVER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 E 13TH ST SUITE 100
TULSA OK
74104-4419
US

IV. Provider business mailing address

1809 E 13TH ST SUITE 100
TULSA OK
74104-4419
US

V. Phone/Fax

Practice location:
  • Phone: 918-582-6800
  • Fax: 918-582-6060
Mailing address:
  • Phone: 918-582-6800
  • Fax: 918-582-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2004
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: