Provider Demographics
NPI:1679314884
Name:PURGASON, STETSON WAYNE
Entity type:Individual
Prefix:
First Name:STETSON
Middle Name:WAYNE
Last Name:PURGASON
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 1:5404 MALPASO CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-4882
Mailing Address - Country:US
Mailing Address - Phone:580-484-4900
Mailing Address - Fax:
Practice Address - Street 1:416 S MUSTANG RD STE B
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-7314
Practice Address - Country:US
Practice Address - Phone:405-254-7746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPCCANDIDATE12208101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health