Provider Demographics
NPI:1770821134
Name:PEIXOTTO, BRUCE (NP)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:PEIXOTTO
Suffix:
Gender:M
Credentials:NP
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4845 S SHERIDAN RD
Mailing Address - Street 2:SUITE 509
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-5751
Mailing Address - Country:US
Mailing Address - Phone:918-660-0031
Mailing Address - Fax:918-660-0056
Practice Address - Street 1:4845 S SHERIDAN RD
Practice Address - Street 2:SUITE 509
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-5751
Practice Address - Country:US
Practice Address - Phone:918-660-0031
Practice Address - Fax:918-660-0056
Is Sole Proprietor?:No
Enumeration Date:2013-01-19
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK87242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200511020AMedicaid