Provider Demographics
NPI:1114716172
Name:DEANE, MIK'QUAN CARLOS
Entity type:Individual
Prefix:
First Name:MIK'QUAN
Middle Name:CARLOS
Last Name:DEANE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 S RIVERFRONT DR APT 305
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3907
Mailing Address - Country:US
Mailing Address - Phone:918-607-0447
Mailing Address - Fax:
Practice Address - Street 1:204 S RIVERFRONT DR APT 305
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3907
Practice Address - Country:US
Practice Address - Phone:918-607-0447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator