Healthcare Provider Details

I. General information

NPI: 1437626389
Provider Name (Legal Business Name): BRIAN GOODRICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 06/02/2020
Certification Date: 06/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6151 S YALE AVE STE 2403
TULSA OK
74136-1907
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 918-494-1710
  • Fax: 918-494-1715
Mailing address:
  • Phone: 918-488-6687
  • Fax: 918-502-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number109660
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: