| Nerve Renewal Stillwater | |
|
1411 W 12th Ave Ste D Stillwater OK 74074-5482 | |
| (405) 724-6902 | |
| (405) 669-3517 |
| Full Name | Nerve Renewal Stillwater |
|---|---|
| Speciality | Physical Medicine & Rehabilitation |
| Location | 1411 W 12th Ave Ste D, Stillwater, Oklahoma |
| Authorized Official Name and Position | Timothy C Bales (OWNER/CEO) |
| Authorized Official Contact | 4059537221 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Nerve Renewal Stillwater 3705 Nw 63rd St Ste 200 Oklahoma City OK 73116-1937 Ph: (405) 953-7221 | Nerve Renewal Stillwater 1411 W 12th Ave Ste D Stillwater OK 74074-5482 Ph: (405) 724-6902 |
| NPI Number | 1518708635 |
|---|---|
| Provider Enumeration Date | 06/03/2024 |
| Last Update Date | 08/13/2026 |
| Certification Date | 08/13/2026 |
| Medicare PECOS PAC ID | 9830634419 |
|---|---|
| Medicare Enrollment ID | O20240709000939 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1518708635 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (NU) | Secondary |
| 208100000X | Physical Medicine & Rehabilitation | (NU) | Primary |
| Provider Name | Mark R Woodson |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1225032246 PECOS PAC ID: 6204808801 Enrollment ID: I20040812000522 |
| Provider Name | Shanna L Douglass |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1134607310 PECOS PAC ID: 3870847825 Enrollment ID: I20181112000474 |
| Provider Name | Lisa Y Henderson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1912424243 PECOS PAC ID: 2163755927 Enrollment ID: I20190610002285 |
| Provider Name | Kelly Marlene Johnson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1700345345 PECOS PAC ID: 6103159520 Enrollment ID: I20190617002719 |
| Provider Name | Latrica Louise Dorsey |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1538696083 PECOS PAC ID: 1658777024 Enrollment ID: I20210909003063 |
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Associates of Internal Medicine Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 608 S Hester St, Stillwater, OK 74074 Phone: 405-377-8000 Fax: 405-377-8040 |
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Osu-aj Smc Otolaryngology Clinic Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 1201 S Adams St, Stillwater, OK 74074 Phone: 918-561-8306 Fax: 918-561-5747 |
Stillwater Internal Medicine Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 709 S Western Rd, Stillwater, OK 74074 Phone: 405-707-9800 Fax: 405-707-0004 |
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