Basic Information
| Provider Information | |||||||||
| NPI: | 1629074992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARVIS | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730756613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052385501 | ||||||||
| FaxNumber: | 4052389261 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730756613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052385501 | ||||||||
| FaxNumber: | 4052389261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 09/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3915 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1000097310A | 05 | OK | MEDICAID |