Healthcare Provider Details

I. General information

NPI: 1689308918
Provider Name (Legal Business Name): NICKOLAS BRYANT CAMPBELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NICK BRYANT CAMPBELL

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 E 81ST ST STE 290
TULSA OK
74137-4299
US

IV. Provider business mailing address

2488 E 81ST ST STE 290
TULSA OK
74137-4299
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2665
  • Fax: 918-927-3201
Mailing address:
  • Phone: 918-494-2665
  • Fax: 918-927-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5439
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: