Provider Demographics
NPI:1255196697
Name:MCMILLAN, KOURTLAND BLAIR
Entity type:Individual
Prefix:
First Name:KOURTLAND
Middle Name:BLAIR
Last Name:MCMILLAN
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 1:215 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 NE 1ST STREET
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:OK
Practice Address - Zip Code:74467-6928
Practice Address - Country:US
Practice Address - Phone:918-201-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist