Provider Demographics
NPI:1659612281
Name:LAFUENTE, BRYAN HENRY (CP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:HENRY
Last Name:LAFUENTE
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 NW 9TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-2619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:229 NW 9TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-2619
Practice Address - Country:US
Practice Address - Phone:405-974-1548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100807050AMedicaid
OK5200600001OtherMEDICARE PTAN
OK5200600001Medicare NSC