Healthcare Provider Details

I. General information

NPI: 1386513703
Provider Name (Legal Business Name): LOGAN REVILL APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

23003 E 104TH ST S
BROKEN ARROW OK
74014-6256
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2200
  • Fax:
Mailing address:
  • Phone: 918-760-6709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberR0133810
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: