Healthcare Provider Details

I. General information

NPI: 1881013365
Provider Name (Legal Business Name): ANDREA CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 N MARTIN LUTHER KING JR BLVD
TULSA OK
74106-6447
US

IV. Provider business mailing address

650 S PEORIA AVE
TULSA OK
74120-4429
US

V. Phone/Fax

Practice location:
  • Phone: 918-425-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: