Provider Demographics
NPI:1689308918
Name:CAMPBELL, NICKOLAS BRYANT
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:BRYANT
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:BRYANT
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4299
Mailing Address - Country:US
Mailing Address - Phone:918-494-2665
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2488 E 81ST ST STE 290
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4299
Practice Address - Country:US
Practice Address - Phone:918-494-2665
Practice Address - Fax:918-927-3201
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
OK5439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program