MEDICARE: MITCHELL HASTINGS RN

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	163WE0003X	Emergency Registered Nurse	R0131768	OK

General Provider Information

NPI Number	:	1528523008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL HASTINGS RN

Provider Business Mailing Address
First Line	:	904 NW 109TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-6908
Country	:	US
Telephone Number	:	425-343-8044
Fax Number	:

Provider Business Practice Location Address
First Line	:	904 NW 109TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-6908
Country	:	US
Telephone Number	:	425-343-8044
Fax Number	:

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

Provider Enumeration Date	:	02/08/2019
Last Update Date	:	02/08/2019

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