Provider Demographics
NPI:1568820140
Name:BLACK, MEGAN ELIZABETH (APRN, C-NP)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN, C-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-3902
Mailing Address - Country:US
Mailing Address - Phone:580-584-3099
Mailing Address - Fax:844-716-2493
Practice Address - Street 1:110 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728
Practice Address - Country:US
Practice Address - Phone:580-584-3099
Practice Address - Fax:580-584-3097
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK100330363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200636630AMedicaid