Provider Demographics
NPI:1124512322
Name:FULCRUM CLINIC LLC
Entity type:Organization
Organization Name:FULCRUM CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER AND CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:FERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-546-7888
Mailing Address - Street 1:1601 SW 89TH ST STE D100
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6378
Mailing Address - Country:US
Mailing Address - Phone:405-546-7888
Mailing Address - Fax:844-518-2784
Practice Address - Street 1:1601 SW 89TH ST STE D100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6378
Practice Address - Country:US
Practice Address - Phone:405-546-7888
Practice Address - Fax:844-518-2784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK72566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1497170526OtherINSURANCE
OK1497170526Medicaid