Provider Demographics
NPI:1306499603
Name:MYERS, CHARLES HENRY II
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HENRY
Last Name:MYERS
Suffix:II
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 1:13003 S 5TH PL
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-4448
Mailing Address - Country:US
Mailing Address - Phone:918-652-5407
Mailing Address - Fax:
Practice Address - Street 1:1313 E 20TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6303
Practice Address - Country:US
Practice Address - Phone:918-591-5700
Practice Address - Fax:918-758-1944
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK95442163WM0705X
OK95422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Multi-Specialty