MEDICARE: STATE OF OKLAHOMA

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	291U00000X	Clinical Medical Laboratory	37D2076904	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447662010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF OKLAHOMA

Provider Business Mailing Address
First Line	:	1111 W 17TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74107-1886
Country	:	US
Telephone Number	:	918-561-1421
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 W 17TH ST
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74107-1886
Country	:	US
Telephone Number	:	918-561-1421
Fax Number	:

Authorized Official
Title or Position	:	ASSOCIATE PROFESSOR & DIRECTOR
Name	:	DR. JARRAD R WAGNER
Credential	:	PHD
Telephone Number	:	918-561-8247

Provider Enumeration Date	:	05/29/2014
Last Update Date	:	08/31/2017

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1326495433 — OKLAHOMA STATE UNIVERSITY
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Directions to “STATE OF OKLAHOMA ” Practice Location

Language	Start Address	Practice Location

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