Provider Demographics
NPI:1790303386
Name:FUGATE, MARIAH ASHLEY
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ASHLEY
Last Name:FUGATE
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 1:321 SE 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6714
Mailing Address - Country:US
Mailing Address - Phone:405-821-0418
Mailing Address - Fax:
Practice Address - Street 1:100 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5207
Practice Address - Country:US
Practice Address - Phone:405-974-5239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer