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General NPI Number Information
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NPI Number | 1003772765
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Entity Type | Organization
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Legal Business Name | FRONTIER REGENERATION GROUP
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Dates
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Enumeration Date | 12/26/2025
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Last Update Date | 12/26/2025
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Provider Practice Location Address
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Address Line | 601 NW 198TH ST
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City | EDMOND
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State | OK
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Zip | 73012-1317
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Country | US
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Telephone | 216-224-6402
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Fax |
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Provider Business Mailing Address
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Address Line | 601 NW 198TH ST
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City | EDMOND
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State | OK
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Zip | 73012-1317
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | JORDAN TISDALE
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Credential |
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Telephone | 216-224-6402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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