Basic Information
| Provider Information | |||||||||
| NPI: | 1689652075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOKES | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | ALTON | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3062 FOXDEN RD | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734017751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5806572587 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1105 MICHELIN RD | ||||||||
| Address2: | MICHELIN FAMILY HEALTH CENTER | ||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802248750 | ||||||||
| FaxNumber: | 5802244454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
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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 | 207Q00000X | 1919 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | 1919 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100123410A | 05 | OK | MEDICAID |