Provider Demographics
NPI:1417952904
Name:PENDARVIS, BRIAN TRAVIS (ARNP)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:TRAVIS
Last Name:PENDARVIS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SOUTH MAIN STREET
Mailing Address - Street 2:PO BOX 2096
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068
Mailing Address - Country:US
Mailing Address - Phone:405-872-5403
Mailing Address - Fax:405-872-5407
Practice Address - Street 1:205 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068
Practice Address - Country:US
Practice Address - Phone:405-872-5403
Practice Address - Fax:405-872-5407
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0067224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200043980AMedicaid
OK200043980AMedicaid
OK243505300Medicare ID - Type Unspecified