Provider Demographics
NPI:1508408311
Name:WAHL, MARCUS SHANE (APRN)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:SHANE
Last Name:WAHL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2222 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2738
Mailing Address - Country:US
Mailing Address - Phone:405-224-8111
Mailing Address - Fax:405-825-4530
Practice Address - Street 1:200 MELVILLE DR
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-6610
Practice Address - Country:US
Practice Address - Phone:405-224-8111
Practice Address - Fax:405-825-4530
Is Sole Proprietor?:No
Enumeration Date:2019-10-14
Last Update Date:2023-11-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK58478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily