Basic Information
| Provider Information | |||||||||
| NPI: | 1154486629 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEAGLES | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CCP LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12815 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731572815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 N MAY AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731126641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/26/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | LP63 | OK | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 242T00000X | LP63 | OK | Y | Technologists, Technicians & Other Technical Service Providers | Perfusionist |
ID Information
| ID | Type | State | Issuer | Description | 5993501 | 01 | AETNA | OTHER | 731522080002 | 01 | BCBS | OTHER |