Provider Demographics
NPI:1831795574
Name:SCHAEFER, ALYSSA CAMPOS
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CAMPOS
Last Name:SCHAEFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 S WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5142
Mailing Address - Country:US
Mailing Address - Phone:918-704-7185
Mailing Address - Fax:
Practice Address - Street 1:4103 S YALE AVE STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6002
Practice Address - Country:US
Practice Address - Phone:918-382-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0000000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program