Basic Information
Provider Information | |||||||||
NPI: | 1336511732 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OLDHAM | ||||||||
FirstName: | MEGHAN | ||||||||
MiddleName: | GWYNETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHITE | ||||||||
OtherFirstName: | MEGHAN | ||||||||
OtherMiddleName: | GWYNETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CPNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5865 | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 794085865 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067432898 | ||||||||
FaxNumber: | 8067432787 | ||||||||
Practice Location | |||||||||
Address1: | 602 INDIANA AVE | ||||||||
Address2: |   | ||||||||
City: | LUBBOCK | ||||||||
State: | TX | ||||||||
PostalCode: | 79415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8067758838 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2015 | ||||||||
LastUpdateDate: | 10/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AP129186 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.