Provider Demographics
NPI:1093833220
Name:FRETER, MICHAEL CLARK (ST)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CLARK
Last Name:FRETER
Suffix:
Gender:M
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11251 WESTFALL RD
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-5289
Mailing Address - Country:US
Mailing Address - Phone:918-396-2468
Mailing Address - Fax:
Practice Address - Street 1:1809 E 13TH ST
Practice Address - Street 2:SUITE #400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4419
Practice Address - Country:US
Practice Address - Phone:918-599-8200
Practice Address - Fax:918-583-4678
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NONE246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist