Provider Demographics
NPI:1619560984
Name:TEVEBAUGH, LARRY RAY JR (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:RAY
Last Name:TEVEBAUGH
Suffix:JR
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 NW 134TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5909
Mailing Address - Country:US
Mailing Address - Phone:405-830-5574
Mailing Address - Fax:
Practice Address - Street 1:6600 NW 134TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-5909
Practice Address - Country:US
Practice Address - Phone:405-830-5574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0094181163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice