Provider Demographics
NPI:1780011866
Name:MATLOCK, MAX JOSEPH
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:JOSEPH
Last Name:MATLOCK
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 1:6839 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3402
Mailing Address - Country:US
Mailing Address - Phone:405-590-2913
Mailing Address - Fax:
Practice Address - Street 1:6839 S CANTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3402
Practice Address - Country:US
Practice Address - Phone:405-590-2913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN631383390200000X
OK92790367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program