Provider Demographics
NPI:1073071221
Name:SOMMERS, AUSTIN WAYNE
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:WAYNE
Last Name:SOMMERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 SEMINOLE TRL
Mailing Address - Street 2:
Mailing Address - City:SPAVINAW
Mailing Address - State:OK
Mailing Address - Zip Code:74366-1116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 SEMINOLE TRL
Practice Address - Street 2:
Practice Address - City:SPAVINAW
Practice Address - State:OK
Practice Address - Zip Code:74366-1116
Practice Address - Country:US
Practice Address - Phone:918-812-3994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKH083236016175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist