Provider Demographics
NPI:1639480254
Name:NICK, MICHAEL SHAWN (DO, PHARMD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:NICK
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Gender:M
Credentials:DO, PHARMD
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Mailing Address - Street 1:1611 S UTICA AVE
Mailing Address - Street 2:STE 217
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4909
Mailing Address - Country:US
Mailing Address - Phone:918-744-3664
Mailing Address - Fax:918-748-7688
Practice Address - Street 1:1611 S UTICA AVE
Practice Address - Street 2:STE 217
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4909
Practice Address - Country:US
Practice Address - Phone:918-744-3664
Practice Address - Fax:918-748-7688
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2015-05-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK13532183500000X
OK4937207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No183500000XPharmacy Service ProvidersPharmacist