MEDICARE: FRESH MEDICAL LLC

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	363A00000X	Physician Assistant	817	OK
2	363L00000X	Nurse Practitioner	R0092194	OK

General Provider Information

NPI Number	:	1740664580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRESH MEDICAL LLC

Provider Business Mailing Address
First Line	:	4200 CARRIAGE WAY
Second Line	:
City	:	WEATHERFORD
State	:	OK
Zip	:	73096-9614
Country	:	US
Telephone Number	:	580-774-2214
Fax Number	:	580-774-2843

Provider Business Practice Location Address
First Line	:	4200 CARRIAGE WAY
Second Line	:
City	:	WEATHERFORD
State	:	OK
Zip	:	73096-9614
Country	:	US
Telephone Number	:	580-774-2214
Fax Number	:	580-774-2843

Authorized Official
Title or Position	:	OFFICE ADMINSTRATOR
Name	:	ASHLEY DAWN MORRIS
Credential	:	NP
Telephone Number	:	580-774-2214

Provider Enumeration Date	:	07/10/2015
Last Update Date	:	07/10/2015

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