Provider Demographics
NPI:1285840660
Name:BRAY, NATASHA NICHOLE (DO)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:NICHOLE
Last Name:BRAY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112604 S 4710 RD
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-6862
Mailing Address - Country:US
Mailing Address - Phone:918-817-2576
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-280-1845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS100045207R00000X
ARE-9090207R00000X
OK6108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine