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General NPI Number Information
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NPI Number | 1447662010
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Entity Type | Organization
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Legal Business Name | STATE OF OKLAHOMA
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Dates
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Enumeration Date | 05/29/2014
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Last Update Date | 08/31/2017
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Provider Practice Location Address
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Address Line | 1111 W 17TH ST
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City | TULSA
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State | OK
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Zip | 74107-1886
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Country | US
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Telephone | 918-561-1421
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Fax |
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Provider Business Mailing Address
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Address Line | 1111 W 17TH ST
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City | TULSA
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State | OK
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Zip | 74107-1886
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Country | US
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Telephone | 918-561-1421
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Fax |
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Authorized Official
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Title or Position | ASSOCIATE PROFESSOR & DIRECTOR
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Name | DR. JARRAD R WAGNER
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Credential | PHD
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Telephone | 918-561-8247
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 37D2076904
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License Number State | OK
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