Provider Demographics
NPI:1740744945
Name:BUNDRICK, NELSON S
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:S
Last Name:BUNDRICK
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 1:428 S MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6946
Mailing Address - Country:US
Mailing Address - Phone:405-577-5477
Mailing Address - Fax:
Practice Address - Street 1:428 S MUSTANG RD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6946
Practice Address - Country:US
Practice Address - Phone:405-577-5477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator