Provider Demographics
NPI:1194597773
Name:PENNINGTON, MICHAEL CRIS
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRIS
Last Name:PENNINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11604 E 23RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-5602
Mailing Address - Country:US
Mailing Address - Phone:918-630-6029
Mailing Address - Fax:
Practice Address - Street 1:11604 E 23RD ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5602
Practice Address - Country:US
Practice Address - Phone:918-630-6029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist