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General NPI Number Information
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NPI Number | 1508408311
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Entity Type | Individual
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Provider Name | MARCUS SHANE WAHL APRN
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Gender | Male
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Dates
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Enumeration Date | 10/14/2019
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Last Update Date | 04/16/2025
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Provider Practice Location Address
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Address Line | 1007 N COUNTRY CLUB RD
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City | ADA
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State | OK
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Zip | 74820-2847
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Country | US
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Telephone | 580-421-8700
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Fax | 580-272-1094
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Provider Business Mailing Address
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Address Line | 2222 W IOWA AVE
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City | CHICKASHA
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State | OK
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Zip | 73018-2738
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Country | US
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Telephone | 405-224-8111
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Fax | 405-825-4530
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 58478
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License Number State | OK
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