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General NPI Number Information
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NPI Number | 1972907202
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Entity Type | Individual
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Provider Name | TAMARA KEISHA WOLESTON M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/15/2014
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Last Update Date | 04/03/2017
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Provider Practice Location Address
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Address Line | 1111 S SAINT LOUIS AVE
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City | TULSA
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State | OK
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Zip | 74120-5440
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Country | US
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Telephone | 918-619-4600
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Fax |
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Provider Business Mailing Address
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Address Line | 1835 E 16TH PL
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City | TULSA
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State | OK
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Zip | 74104-4923
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Country | US
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Telephone | 973-330-7832
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 30410
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License Number State | OK
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