Provider Demographics
NPI:1104294818
Name:OKLAHOMA STATE UNIVERSITY
Entity type:Organization
Organization Name:OKLAHOMA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:KYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-440-0005
Mailing Address - Street 1:102 E BRAHMA AVE
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:OK
Mailing Address - Zip Code:74029-2712
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-599-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0106977261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty