Basic Information
| Provider Information | |||||||||
| NPI: | 1891429163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDGENS | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 E 19TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187442630 | ||||||||
| FaxNumber: | 9187442946 | ||||||||
| Practice Location | |||||||||
| Address1: | 12455 E 100TH ST N STE 350 | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740554675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182745510 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2022 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 209154 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.