Basic Information
| Provider Information | |||||||||
| NPI: | 1063465409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLEFORD | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | AUSTIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94670 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731434670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056823303 | ||||||||
| FaxNumber: | 4053846793 | ||||||||
| Practice Location | |||||||||
| Address1: | 1018 N MOUND ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | NACOGDOCHES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759614434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365694150 | ||||||||
| FaxNumber: | 9365694155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 631071 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.