Provider Demographics
NPI:1528409224
Name:BOHAN, MARY R (APRN-CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:BOHAN
Suffix:
Gender:F
Credentials:APRN-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E 55TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7212
Mailing Address - Country:US
Mailing Address - Phone:918-743-5510
Mailing Address - Fax:
Practice Address - Street 1:2625 E 55TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7212
Practice Address - Country:US
Practice Address - Phone:918-743-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0074856367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife