MEDICARE: THOMAS TEDFORD COOK APRN

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	363LP2300X	Primary Care Nurse Practitioner	R102398	OK

General Provider Information

NPI Number	:	1336627223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS TEDFORD COOK APRN

Provider Business Mailing Address
First Line	:	5700 N PORTLAND AVE STE 102
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-1650
Country	:	US
Telephone Number	:	405-942-5513
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 N PORTLAND AVE STE 102
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-1650
Country	:	US
Telephone Number	:	405-942-5513
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2018
Last Update Date	:	01/22/2020

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