Provider Demographics
NPI:1407541618
Name:BOTONE, BARRY LUKE (PRSS)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:LUKE
Last Name:BOTONE
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RED MOON CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CONCHO
Mailing Address - State:OK
Mailing Address - Zip Code:73022
Mailing Address - Country:US
Mailing Address - Phone:405-422-7452
Mailing Address - Fax:
Practice Address - Street 1:100 RED MOON CIRCLE
Practice Address - Street 2:
Practice Address - City:CONCHO
Practice Address - State:OK
Practice Address - Zip Code:73022-7302
Practice Address - Country:US
Practice Address - Phone:405-422-7452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist