Provider Demographics
NPI:1811231939
Name:BEESLEY GRAY, WANDA LUANN (EMT-P)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LUANN
Last Name:BEESLEY GRAY
Suffix:
Gender:F
Credentials:EMT-P
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:LUANN
Other - Last Name:BEESLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 E ST HWY 78
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460
Mailing Address - Country:US
Mailing Address - Phone:580-257-0499
Mailing Address - Fax:
Practice Address - Street 1:3100 E ST HWY 78
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460
Practice Address - Country:US
Practice Address - Phone:580-257-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9208146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic