Provider Demographics
NPI:1023302007
Name:MATHES, NICOLE PAOLA (MD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:PAOLA
Last Name:MATHES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:VERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1923 S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-6520
Mailing Address - Country:US
Mailing Address - Phone:918-403-7065
Mailing Address - Fax:918-744-2946
Practice Address - Street 1:800 W BOISE CIR STE 160
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4932
Practice Address - Country:US
Practice Address - Phone:918-994-9166
Practice Address - Fax:918-403-6306
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS3238207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX427183501Medicaid
TX427183502Medicaid
OK201278690AMedicaid