Basic Information
| Provider Information | |||||||||
| NPI: | 1821169590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DENTON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BURKHART | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURKHART | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | C. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1701 RENAISSANCE BLVD | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444978 | ||||||||
| FaxNumber: | 4058440562 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 RENAISSANCE BLVD | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730133086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444978 | ||||||||
| FaxNumber: | 4058440562 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 207906 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 45190 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 95000713 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | AP4675 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 10001631801 | 01 | CHP PROVIDER NUMBER | OTHER | 100446630A | 05 | KS | MEDICAID | P01137754 | 01 | AZ | RAILROAD MEDICARE | OTHER | 002828500 | 05 | FL | MEDICAID | 757385 | 05 | AZ | MEDICAID | 481202402 | 01 | PSKU TAX ID | OTHER | 500028442 | 01 | RR MEDICARE | OTHER | 511800 | 01 | FIRSTGUARD | OTHER | 427250709 | 05 | MO | MEDICAID | 6544 | 01 | PHS PROVIDER NUMBER | OTHER |