1669845772 NPI number — MR. JEREMY MICHAEL HURFORD PA-C

Table of content: MR. JEREMY MICHAEL HURFORD PA-C (NPI 1669845772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669845772 NPI number — MR. JEREMY MICHAEL HURFORD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HURFORD
Provider First Name:
JEREMY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1669845772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 389
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKEENE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73763-0389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-822-4404
Provider Business Mailing Address Fax Number:
580-822-4403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 N 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKEENE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73763-9135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-833-4404
Provider Business Practice Location Address Fax Number:
580-822-4403
Provider Enumeration Date:
11/11/2015

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: 363A00000X , with the licence number:  2599 , 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: 471025ZL9Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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