Provider Demographics
NPI:1124185517
Name:WYANDOTTE NATION
Entity Type:Organization
Organization Name:WYANDOTTE NATION
Other - Org Name:BEARSKIN HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIEND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-678-2282
Mailing Address - Street 1:1 TURTLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:OK
Mailing Address - Zip Code:74370
Mailing Address - Country:US
Mailing Address - Phone:918-678-2282
Mailing Address - Fax:918-678-2759
Practice Address - Street 1:1 TURTLE DRIVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:OK
Practice Address - Zip Code:74370
Practice Address - Country:US
Practice Address - Phone:918-678-2282
Practice Address - Fax:918-678-2759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100707880AMedicaid
OK100732740BMedicaid