Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 4316 | OK |
Y | 207Q00000X | Family Doctor | 4316 | OK |
NPI | 1003806704 |
---|---|
Provider Name | Eric W Mix |
First Address | Tulsa, OK 74114-1711 |
Second Address | Muskogee, OK 74401-5075 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/10/2005 |
Last Update Date | 31/08/2009 |