Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 5279 | OK |
NPI | 1003384546 |
---|---|
Provider Name | Jovan Pride |
First Address | Edmond, OK 73013-1894 |
Second Address | Oklahoma City, OK 73135-1104 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/11/2018 |
Last Update Date | 14/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200802530A | (05) | OK |