Provider Demographics
NPI:1083340418
Name:NUSBAUM, ADAM SHANE
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:SHANE
Last Name:NUSBAUM
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 1:1400 SE 4TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-7328
Mailing Address - Country:US
Mailing Address - Phone:405-837-1033
Mailing Address - Fax:
Practice Address - Street 1:1400 SE 4TH ST STE A
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-7328
Practice Address - Country:US
Practice Address - Phone:405-837-1033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator