Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 29225 | OK |
Y | 207QS0010X | Family Doctor - Sports Medicine | 29225 | OK |
NPI | 1255699435 |
---|---|
Provider Name | Peter Fast |
First Address | Tulsa, OK 74136-3333 |
Second Address | Muskogee, OK 74401-4078 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/04/2012 |
Last Update Date | 28/03/2018 |