Provider Demographics
NPI:1366438715
Name:MINOR, SHAWN E (DO)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:E
Last Name:MINOR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 S UTICA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5346
Mailing Address - Country:US
Mailing Address - Phone:866-321-8433
Mailing Address - Fax:
Practice Address - Street 1:1200 N MUSKOGEE PL
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3058
Practice Address - Country:US
Practice Address - Phone:918-341-2556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3974207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200006980BMedicaid
OK200006980BMedicaid
OK245515104Medicare ID - Type Unspecified