Provider Demographics
NPI:1679044747
Name:PAUL, THERON MARKKELL
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:MARKKELL
Last Name:PAUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E 42ND ST N
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-1320
Mailing Address - Country:US
Mailing Address - Phone:918-814-0107
Mailing Address - Fax:
Practice Address - Street 1:730 E 42ND ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1320
Practice Address - Country:US
Practice Address - Phone:918-814-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator