Healthcare Provider Details

I. General information

NPI: 1962793018
Provider Name (Legal Business Name): MIRANDA CELESTE GASKAMP D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 W 9TH ST
TULSA OK
74127-9020
US

IV. Provider business mailing address

1717 S UTICA AVE STE A
TULSA OK
74104-5346
US

V. Phone/Fax

Practice location:
  • Phone: 918-587-2561
  • Fax:
Mailing address:
  • Phone: 918-519-8364
  • Fax:

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 State
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5213
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: