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General NPI Number Information
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NPI Number | 1063525954
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Entity Type | Organization
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Legal Business Name | CANYON PARK MEDICAL GROUP, PLLC
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 05/02/2011
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Provider Practice Location Address
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Address Line | 1501 E 19TH ST
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City | EDMOND
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State | OK
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Zip | 73013-6618
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Country | US
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Telephone | 405-348-6611
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Fax | 405-348-9280
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Provider Business Mailing Address
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Address Line | 1501 E 19TH ST
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City | EDMOND
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State | OK
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Zip | 73013-6618
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Country | US
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Telephone | 405-348-6611
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Fax | 405-348-9280
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Authorized Official
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Title or Position | CLINIC MANAGER
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Name | TONYA LYNN KEITH
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Credential |
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Telephone | 405-348-6611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 8699
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License Number State | OK
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