Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | A004509 | AR |
NPI | 1053787283 |
---|---|
Provider Name | Amanda Combs |
First Address | Pocola, OK 74902-2463 |
Second Address | Pocola, OK 74902-2463 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/08/2015 |
Last Update Date | 11/08/2015 |