Provider Demographics
NPI:1760254569
Name:GRACE, AARON DEAN
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:DEAN
Last Name:GRACE
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 1:2708 NE 133RD ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5690
Mailing Address - Country:US
Mailing Address - Phone:405-938-5936
Mailing Address - Fax:
Practice Address - Street 1:2625 GENERAL PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6437
Practice Address - Country:US
Practice Address - Phone:405-945-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator