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General NPI Number Information
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NPI Number | 1801424346
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Entity Type | Individual
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Provider Name | JACK MANQUEN
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Gender | Male
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Dates
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Enumeration Date | 03/30/2020
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Last Update Date | 07/01/2025
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Provider Practice Location Address
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Address Line | 1724 S HARVARD AVE
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City | TULSA
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State | OK
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Zip | 74112-6826
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Country | US
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Telephone | 405-730-6990
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Fax | 405-730-6992
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Provider Business Mailing Address
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Address Line | 1706 S CEDAR AVE
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City | BROKEN ARROW
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State | OK
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Zip | 74012-6407
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Country | US
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Telephone | 586-214-8344
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Fax |
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 7329
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 2080S0010X
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Taxonomy Name | Pediatric Sports Medicine Physician
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License Number | 010269
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License Number State | AZ
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