Basic Information
| Provider Information | |||||||||
| NPI: | 1366438715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINOR | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 S UTICA AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663218433 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 N MUSKOGEE PL | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183412556 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 3974 | OK | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 200006980B | 05 | OK | MEDICAID |