Provider Demographics
NPI:1265132922
Name:ASFAHA, TEDROS ABBAY (APRN)
Entity type:Individual
Prefix:
First Name:TEDROS
Middle Name:ABBAY
Last Name:ASFAHA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 N 22ND ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2319
Mailing Address - Country:US
Mailing Address - Phone:918-640-5088
Mailing Address - Fax:
Practice Address - Street 1:1500 N 22ND ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2319
Practice Address - Country:US
Practice Address - Phone:918-640-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKF02230673363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily