MEDICARE: JOHN MATTHEW ANTONELLI

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	363LF0000X	Family Nurse Practitioner	108524	OK

General Provider Information

NPI Number	:	1902773021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN MATTHEW ANTONELLI

Provider Business Mailing Address
First Line	:	1313 S 221ST WEST AVE
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-5177
Country	:	US
Telephone Number	:	918-289-5583
Fax Number	:

Provider Business Practice Location Address
First Line	:	1313 S 221ST WEST AVE
Second Line	:
City	:	SAND SPRINGS
State	:	OK
Zip	:	74063-5177
Country	:	US
Telephone Number	:	918-289-5583
Fax Number	:

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

Provider Enumeration Date	:	10/22/2025
Last Update Date	:	12/05/2025

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