Provider Demographics
NPI:1356150569
Name:BRZOZOWSKI, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BRZOZOWSKI
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2103
Mailing Address - Country:US
Mailing Address - Phone:405-295-1500
Mailing Address - Fax:
Practice Address - Street 1:1801 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-2103
Practice Address - Country:US
Practice Address - Phone:405-295-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant