Provider Demographics
NPI:1831730142
Name:CONKLING, JUSTIN ANTHONY
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ANTHONY
Last Name:CONKLING
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 1:18101 SE44TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEWALLA
Mailing Address - State:OK
Mailing Address - Zip Code:74857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18101 SE44TH STREET
Practice Address - Street 2:
Practice Address - City:NEWALLA
Practice Address - State:OK
Practice Address - Zip Code:74857
Practice Address - Country:US
Practice Address - Phone:405-651-1879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist