Healthcare Provider Details

I. General information

NPI: 1366674772
Provider Name (Legal Business Name): WAGONER HOSPITAL AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 W CHEROKEE ST STE E
WAGONER OK
74467-4629
US

IV. Provider business mailing address

1200 W CHEROKEE ST
WAGONER OK
74467-4624
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-1877
  • Fax: 918-485-0535
Mailing address:
  • Phone: 918-485-5514
  • Fax: 918-485-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number2298
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number2298
License Number StateOK

VIII. Authorized Official

Name: JUDITH ELIZABETH BROWN
Title or Position: BUSINESS OPERATIONS DIRECTOR
Credential:
Phone: 918-485-1297