Provider Demographics
NPI:1891026902
Name:NORTHEASTERN OKLAHOMA ADVANCED NEUROTHERAPEUTICS LLC
Entity type:Organization
Organization Name:NORTHEASTERN OKLAHOMA ADVANCED NEUROTHERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAJARA-NANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-338-3781
Mailing Address - Street 1:3450 E FRANK PHILLIPS BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2406
Mailing Address - Country:US
Mailing Address - Phone:918-338-3781
Mailing Address - Fax:918-338-3782
Practice Address - Street 1:3450 E FRANK PHILLIPS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2406
Practice Address - Country:US
Practice Address - Phone:918-338-3781
Practice Address - Fax:918-338-3782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK256102084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty