Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 5800 | OK |
Y | 207QS0010X | Family Doctor - Sports Medicine | 5800 | OK |
NPI | 1154736346 |
---|---|
Provider Name | Dr. Joshua Priddle |
First Address | Konawa, OK 74849-1415 |
Second Address | Ada, OK 74820-2329 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2014 |
Last Update Date | 18/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5800 | OK STATE BOARD OF OSTEOPATHIC EXAMINERS (01) | OK |