MEDICARE: GILSTRAP CLINICS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1063877017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GILSTRAP CLINICS PC

Provider Business Mailing Address
First Line	:	3900 S 113TH WEST AVE
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-2724
Country	:	US
Telephone Number	:	918-241-3901
Fax Number	:	918-241-3902

Provider Business Practice Location Address
First Line	:	3900 S 113TH WEST AVE
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-2724
Country	:	US
Telephone Number	:	918-241-3901
Fax Number	:	918-241-3902

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	DR. RUSSELL D GILSTRAP
Credential	:	DC-APRN-CNP
Telephone Number	:	918-241-3901

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	12/17/2015

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