Basic Information
| Provider Information | |||||||||
| NPI: | 1699275982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | MIRANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 573 NE VALLEY VIEW RD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735078015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5809172286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 802 S JACKSON AVE STE 505 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187475322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2018 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 6806 | OK | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.