Provider Demographics
NPI:1669498051
Name:GRATZ, ADDIE BETH (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:BETH
Last Name:GRATZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 849
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-0849
Mailing Address - Country:US
Mailing Address - Phone:580-564-0500
Mailing Address - Fax:580-564-0250
Practice Address - Street 1:9 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-6562
Practice Address - Country:US
Practice Address - Phone:580-564-0500
Practice Address - Fax:580-564-0250
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0067529363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP79030Medicare UPIN