Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | 20806 | OK |
NPI | 1376546531 |
---|---|
Provider Name | Dr. Timothy Pettingell |
First Address | Tulsa, OK 74133-5717 |
Second Address | Tulsa, OK 74137-2807 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2005 |
Last Update Date | 29/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100251620A | (05) | OK |
G75926 | (02) | OK |