Healthcare Provider Details

I. General information

NPI: 1376501189
Provider Name (Legal Business Name): MARK WAYNE PERDUE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S UTICA AVE STE A
TULSA OK
74104-5346
US

IV. Provider business mailing address

1515 N HARVARD AVE STE E
TULSA OK
74115-4957
US

V. Phone/Fax

Practice location:
  • Phone: 918-748-7557
  • Fax: 918-748-7514
Mailing address:
  • Phone: 918-832-6049
  • Fax: 918-832-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1317
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: