1740548551 NPI number — KARISSA MISNER PLLC

Table of content: (NPI 1740548551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740548551 NPI number — KARISSA MISNER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KARISSA MISNER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1740548551
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1216 E KENOSHA ST
Provider Second Line Business Mailing Address:
PMB 326
Provider Business Mailing Address City Name:
BROKEN ARROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74012-2007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-615-6581
Provider Business Mailing Address Fax Number:
918-893-1242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 ROCKEFELLER DR
Provider Second Line Business Practice Location Address:
REHABILITATION UNIT
Provider Business Practice Location Address City Name:
MUSKOGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74401-5075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-684-2522
Provider Business Practice Location Address Fax Number:
918-684-2493
Provider Enumeration Date:
04/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MISNER
Authorized Official First Name:
KARISSA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
918-894-9162

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  4643 , 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: 200474240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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