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General NPI Number Information
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NPI Number | 1457008955
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Entity Type | Individual
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Provider Name | MR. BRADLEY DEWAYNE CLARK
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Gender | Male
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Dates
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Enumeration Date | 03/04/2022
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Last Update Date | 03/04/2022
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Provider Practice Location Address
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Address Line | 252 W 17TH PL
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City | TULSA
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State | OK
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Zip | 74119-4654
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Country | US
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Telephone | 918-200-9065
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Fax | 918-585-9543
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Provider Business Mailing Address
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Address Line | 1620 S ELWOOD AVE APT L3
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City | TULSA
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State | OK
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Zip | 74119-4252
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Country | US
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Telephone | 214-603-3301
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Fax | 918-585-9543
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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