Basic Information
| Provider Information | |||||||||
| NPI: | 1104263425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNUDSEN | ||||||||
| FirstName: | SHELTON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2906 N 17TH ST | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740129568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058083214 | ||||||||
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| Practice Location | |||||||||
| Address1: | 744 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185991000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | E-9687 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 5582 | OK | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.