Provider Demographics
NPI:1790230985
Name:BACH, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:BACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 NW 9TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-7248
Mailing Address - Country:US
Mailing Address - Phone:405-815-5050
Mailing Address - Fax:405-815-5051
Practice Address - Street 1:800 NW 9TH ST STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-7248
Practice Address - Country:US
Practice Address - Phone:405-815-5050
Practice Address - Fax:405-815-5051
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK106661363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty