Healthcare Provider Details

I. General information

NPI: 1871081703
Provider Name (Legal Business Name): SAMIRA POLINA QUEEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6465 S YALE AVE STE 910
TULSA OK
74136-7823
US

IV. Provider business mailing address

6600 S YALE AVE STE 1400
TULSA OK
74136-3331
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-3200
  • Fax: 918-502-3205
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number103075
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number103075
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: