Provider Demographics
NPI:1093225989
Name:FOFANG, CHARLES M (NP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:FOFANG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26901
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-0901
Mailing Address - Country:US
Mailing Address - Phone:405-271-4351
Mailing Address - Fax:405-271-8695
Practice Address - Street 1:1122 NE 13TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1039
Practice Address - Country:US
Practice Address - Phone:405-271-4351
Practice Address - Fax:405-271-8695
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKF10170079363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner