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General NPI Number Information
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NPI Number | 1669080891
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Entity Type | Organization
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Legal Business Name | PRAIRIE GARDENS MEDICAL LLC
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Dates
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Enumeration Date | 07/14/2020
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Last Update Date | 09/16/2020
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Provider Practice Location Address
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Address Line | 1213 NW 122ND ST STE 401
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City | OKLAHOMA CITY
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State | OK
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Zip | 73114-7000
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Country | US
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Telephone | 405-962-8123
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Fax | 405-962-8125
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Provider Business Mailing Address
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Address Line | 175 LARY LN
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City | GUTHRIE
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State | OK
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Zip | 73044-6542
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Country | US
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Telephone | 405-962-8123
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Fax | 405-962-8125
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DIANNE G TUPPER
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Credential | RN/OPAC
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Telephone | 405-742-8898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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