Provider Demographics
NPI:1730335852
Name:TULLIS, CHARLES A (CFA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:A
Last Name:TULLIS
Suffix:
Gender:M
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 13TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-2989
Mailing Address - Country:US
Mailing Address - Phone:918-786-3391
Mailing Address - Fax:918-786-7264
Practice Address - Street 1:601 E 13TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2989
Practice Address - Country:US
Practice Address - Phone:918-786-3391
Practice Address - Fax:918-786-7264
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
110121OtherCERTIFICATION #