1164829057 NPI number — SEAN ANDERSON AGACNP-BC

Table of content: SEAN ANDERSON AGACNP-BC (NPI 1164829057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164829057 NPI number — SEAN ANDERSON AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON
Provider First Name:
SEAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164829057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 RENAISSANCE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73013-3086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-844-4978
Provider Business Mailing Address Fax Number:
405-844-0562

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 S ORCHARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STILLWATER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74074-4218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-780-6650
Provider Business Practice Location Address Fax Number:
405-844-0562
Provider Enumeration Date:
11/20/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  APN19170 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: APN19170 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 19170 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)