Provider Demographics
NPI:1699559633
Name:FIFE, BLAINE MATTHEW
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:MATTHEW
Last Name:FIFE
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 1:112 S 64TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-5720
Mailing Address - Country:US
Mailing Address - Phone:918-892-5949
Mailing Address - Fax:
Practice Address - Street 1:112 S 64TH WEST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-5720
Practice Address - Country:US
Practice Address - Phone:918-892-5949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant