Basic Information
| Provider Information | |||||||||
| NPI: | 1295296812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPENCE | ||||||||
| FirstName: | COREY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 W. 17TH ST., BARSON 241 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741071898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185618432 | ||||||||
| FaxNumber: | 9185618428 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 W. 17TH ST., BARSON 241 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741071898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185618432 | ||||||||
| FaxNumber: | 9185618428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2019 | ||||||||
| LastUpdateDate: | 03/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OK | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.