Basic Information
| Provider Information | |||||||||
| NPI: | 1932712775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 405 E EXCELSIOR AVE | ||||||||
| Address2: | |||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743014226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182566476 | ||||||||
| FaxNumber: | 9185563628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1624 CIMARRON PLZ | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740753467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053722202 | ||||||||
| FaxNumber: | 4056521671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2020 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.