Provider Demographics
NPI:1518115161
Name:VENEGAS, CARLOS JR (ARNP)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:VENEGAS
Suffix:JR
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:CARLOS
Other - Middle Name:
Other - Last Name:VENEGAS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:500 N CLARENCE NASH BLVD
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-2845
Mailing Address - Country:US
Mailing Address - Phone:580-623-7211
Mailing Address - Fax:580-623-7233
Practice Address - Street 1:500 N CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-2845
Practice Address - Country:US
Practice Address - Phone:580-623-7211
Practice Address - Fax:580-623-7233
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46245363LF0000X
OK116073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200590320AMedicaid