Healthcare Provider Details

I. General information

NPI: 1972907202
Provider Name (Legal Business Name): TAMARA KEISHA WOLESTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S SAINT LOUIS AVE
TULSA OK
74120-5440
US

IV. Provider business mailing address

1835 E 16TH PL
TULSA OK
74104-4923
US

V. Phone/Fax

Practice location:
  • Phone: 918-619-4600
  • Fax:
Mailing address:
  • Phone: 973-330-7832
  • 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 StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30410
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: