Basic Information
| Provider Information | |||||||||
| NPI: | 1366441115 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUCKETT | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | HANSON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886045 | ||||||||
| FaxNumber: | 9184886098 | ||||||||
| Practice Location | |||||||||
| Address1: | 6475 S YALE AVE STE 401 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741367818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185029555 | ||||||||
| FaxNumber: | 9185029559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 04/13/2018 | ||||||||
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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 | 207Y00000X | 12175 | OK | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 100078700A | 05 | OK | MEDICAID |