Provider Demographics
NPI:1740980416
Name:ADVANCED PRIMARY CARE CLINIC OF THE STOCKYARDS LLC
Entity type:Organization
Organization Name:ADVANCED PRIMARY CARE CLINIC OF THE STOCKYARDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VEDMIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FONKEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-233-3745
Mailing Address - Street 1:1506 S AGNEW AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73108-2432
Mailing Address - Country:US
Mailing Address - Phone:405-232-3745
Mailing Address - Fax:
Practice Address - Street 1:1506 S AGNEW AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-2432
Practice Address - Country:US
Practice Address - Phone:405-232-3745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty