| NPI | 1679871610 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DENNIS S BLACKSTAD Owner 918-216-4006 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OK 3650) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OK 1327) |
| Enumeration Date | 2011-02-28 |
| Last Update Date | 2023-08-03 |