1487600086 NPI number — ATHENA J FRIESE M.D.

Table of content: ATHENA J FRIESE M.D. (NPI 1487600086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487600086 NPI number — ATHENA J FRIESE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRIESE
Provider First Name:
ATHENA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1487600086
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 N INDEPENDENCE AVE
Provider Second Line Business Mailing Address:
STE 280
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73112-5556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-717-5400
Provider Business Mailing Address Fax Number:
405-717-5467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 HEALTH CENTER PKWY
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
YUKON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73099-6396
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-717-5400
Provider Business Practice Location Address Fax Number:
405-717-5467
Provider Enumeration Date:
05/25/2006

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: 207Q00000X , with the licence number:  14298 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100257020B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com