Basic Information
| Provider Information | |||||||||
| NPI: | 1568892438 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | MS, ARNP, C-FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE STE 1200 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886687 | ||||||||
| FaxNumber: | 9184886098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 E VAN BUREN AVE | ||||||||
| Address2: | |||||||||
| City: | MCALESTER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184218440 | ||||||||
| FaxNumber: | 9184218450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2013 | ||||||||
| LastUpdateDate: | 08/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 86294 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.