Provider Demographics
NPI:1356532022
Name:COOKSON, BRIAN EUGENE (ARNP FNPC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:EUGENE
Last Name:COOKSON
Suffix:
Gender:M
Credentials:ARNP FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-6338
Mailing Address - Country:US
Mailing Address - Phone:918-207-0667
Mailing Address - Fax:918-207-0683
Practice Address - Street 1:26251 HWY 82 SUITE 1
Practice Address - Street 2:
Practice Address - City:PARK HILL
Practice Address - State:OK
Practice Address - Zip Code:74441
Practice Address - Country:US
Practice Address - Phone:918-207-0667
Practice Address - Fax:918-207-0683
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0068390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ58741Medicare UPIN
OK8HE783Medicare PIN