1801275714 NPI number — MRS. BONITA A FERGUSON I D.PSC

Table of content: MRS. BONITA A FERGUSON I D.PSC (NPI 1801275714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801275714 NPI number — MRS. BONITA A FERGUSON I D.PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERGUSON
Provider First Name:
BONITA
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
I
Provider Credential Text:
D.PSC
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:
1801275714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10026 A SOUTH MINGO ROAD
Provider Second Line Business Mailing Address:
#173
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-928-2701
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 E E AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JENKS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74037-3351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-928-2701
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2015

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: 174H00000X , with the licence number:  L 5238622 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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