Healthcare Provider Details

I. General information

NPI: 1790318426
Provider Name (Legal Business Name): PAVEL GREG BUZADZHI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 S UTICA AVE
TULSA OK
74104-4243
US

IV. Provider business mailing address

9228 S MINGO RD STE 200
TULSA OK
74133-5722
US

V. Phone/Fax

Practice location:
  • Phone: 918-592-0999
  • Fax:
Mailing address:
  • Phone: 918-592-0999
  • Fax: 918-592-1021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number106598
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: