Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | R0086862 | OK |
NPI | 1043284292 |
---|---|
Provider Name | Mrs. Andrea S. Wall |
First Address | Tulsa, OK 74133-4564 |
Second Address | Tulsa, OK 74133-4564 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2006 |
Last Update Date | 22/02/2013 |