Healthcare Provider Details

I. General information

NPI: 1467990820
Provider Name (Legal Business Name): LEE MATLOCK APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 S YALE AVE
TULSA OK
74136-1930
US

IV. Provider business mailing address

6600 S YALE AVE STE 1200
TULSA OK
74136-3361
US

V. Phone/Fax

Practice location:
  • Phone: 918-495-2685
  • Fax: 918-495-2660
Mailing address:
  • Phone: 918-488-6653
  • Fax: 918-488-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number109425
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: