Provider Demographics
NPI:1891778122
Name:BACON, JAN LESLIE (APRN)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:LESLIE
Last Name:BACON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N PORTER AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6424
Mailing Address - Country:US
Mailing Address - Phone:405-579-1653
Mailing Address - Fax:405-360-6315
Practice Address - Street 1:700 WALL ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069
Practice Address - Country:US
Practice Address - Phone:405-360-7337
Practice Address - Fax:866-259-0044
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0040808363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK235730901Medicare PIN
OKQ47048Medicare UPIN