Basic Information
Provider Information | |||||||||
NPI: | 1992711345 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHEROKEE NATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WILMA P. MANKILLER HEALTH CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1069 | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744651069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5392342694 | ||||||||
FaxNumber: | 5392342475 | ||||||||
Practice Location | |||||||||
Address1: | 471688 HIGHWAY 51 | ||||||||
Address2: |   | ||||||||
City: | STILWELL | ||||||||
State: | OK | ||||||||
PostalCode: | 749604490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9186968800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2006 | ||||||||
LastUpdateDate: | 11/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: | ROBERT | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, HEALTH SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9186968800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: | 11/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 100689220B | 05 | OK |   | MEDICAID | 370171 | 01 | OK | MEDICARE PART A | OTHER |