MEDICARE: UPTOWN MEDICAL CENTER APRN-CNP, PLLC

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	363LW0102X	Women's Health Nurse Practitioner	421072	NY
2	363LA2200X	Adult Health Nurse Practitioner	83097	OK

General Provider Information

NPI Number	:	1811490691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UPTOWN MEDICAL CENTER APRN-CNP, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 55691
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73155-0691
Country	:	US
Telephone Number	:	405-208-4573
Fax Number	:	405-429-0483

Provider Business Practice Location Address
First Line	:	1207 S SUNNYLANE RD
Second Line	:
City	:	DEL CITY
State	:	OK
Zip	:	73115-3011
Country	:	US
Telephone Number	:	405-208-4573
Fax Number	:	405-429-0483

Authorized Official
Title or Position	:	MEMBER
Name	:	MS. PORSHA LYNN RICHARDSON
Credential	:	NP
Telephone Number	:	405-474-0429

Provider Enumeration Date	:	03/17/2018
Last Update Date	:	03/17/2018

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