Basic Information
| Provider Information | |||||||||
| NPI: | 1891778122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BACON | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Credential: | A.P.R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 N PORTER AVE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055791653 | ||||||||
| FaxNumber: | 4053606315 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 WALL ST | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053607337 | ||||||||
| FaxNumber: | 8662590044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 11/08/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R0040808 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.