Provider Demographics
NPI:1376194373
Name:HISE, CLINT
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:
Last Name:HISE
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 1:101 S MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-5091
Mailing Address - Country:US
Mailing Address - Phone:918-342-6495
Mailing Address - Fax:
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5091
Practice Address - Country:US
Practice Address - Phone:918-342-6495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK109411163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency