Provider Demographics
NPI:1952354755
Name:BULLARD, ROBERT LEE (PAC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LEE
Last Name:BULLARD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9320 S MINGO RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5710
Mailing Address - Country:US
Mailing Address - Phone:918-879-1700
Mailing Address - Fax:918-879-1701
Practice Address - Street 1:9320 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5710
Practice Address - Country:US
Practice Address - Phone:918-879-1700
Practice Address - Fax:918-879-1701
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00283432OtherRAIL ROAD MEDICARE
OK100088420BMedicaid
P00283432OtherRAIL ROAD MEDICARE
OK242421701Medicare ID - Type Unspecified