Provider Demographics
NPI:1720048945
Name:NOSSAMAN, BRENT C (DO)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:C
Last Name:NOSSAMAN
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 1:2448 E 81ST ST STE 1300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4305
Mailing Address - Country:US
Mailing Address - Phone:918-550-8950
Mailing Address - Fax:918-550-8952
Practice Address - Street 1:2448 E 81ST ST STE 1300
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4305
Practice Address - Country:US
Practice Address - Phone:918-550-8950
Practice Address - Fax:918-550-8952
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3041207XS0106X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100195130AMedicaid
OK200036069OtherRAILROAD MEDICARE
F35609Medicare UPIN