Healthcare Provider Details

I. General information

NPI: 1790020873
Provider Name (Legal Business Name): MIKEYA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5550 S GARNETT RD 100
TULSA OK
74146-6831
US

IV. Provider business mailing address

5550 S GARNETT RD 100
TULSA OK
74146-6831
US

V. Phone/Fax

Practice location:
  • Phone: 918-665-2501
  • Fax:
Mailing address:
  • Phone: 918-665-2501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: