Provider Demographics
NPI:1831570910
Name:NICOLE L. CUPP DPM PLLC
Entity type:Organization
Organization Name:NICOLE L. CUPP DPM PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CUPP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:918-331-6422
Mailing Address - Street 1:226 SE DEBELL AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2343
Mailing Address - Country:US
Mailing Address - Phone:918-876-0476
Mailing Address - Fax:918-876-0479
Practice Address - Street 1:226 SE DEBELL AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2343
Practice Address - Country:US
Practice Address - Phone:918-876-0476
Practice Address - Fax:918-876-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-14
Last Update Date:2015-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK301213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200526540AMedicaid
OK200526540AMedicaid