Healthcare Provider Details

I. General information

NPI: 1194322719
Provider Name (Legal Business Name): SPENCER ELIJAH WOPART APRN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2020
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9322 E 41ST ST
TULSA OK
74145-3721
US

IV. Provider business mailing address

1701 RENAISSANCE BLVD
EDMOND OK
73013-3086
US

V. Phone/Fax

Practice location:
  • Phone: 539-215-5609
  • Fax: 539-233-2480
Mailing address:
  • Phone: 405-844-4978
  • Fax: 405-844-4978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number121897
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: