Provider Demographics
NPI:1841057452
Name:GRESHAM, ANTHONY
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25510 E 90TH PLACE SOUTH
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014
Mailing Address - Country:US
Mailing Address - Phone:910-770-6700
Mailing Address - Fax:
Practice Address - Street 1:SKYLINE EAST II
Practice Address - Street 2:6128 E 38TG ST
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74014
Practice Address - Country:US
Practice Address - Phone:800-722-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator