| Doctor Name: | MAKEDA GANT |
| NPI Number: | 1003201039 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 116446 |
| Business Practice Address: | 1129 S Aspen Ave Broken Arrow, OK - 740124859 |
| Business Phone Number: | 9187649300 |
| Business Fax Number: | 9187649275 |
| Mailing Address: | 1129 S Aspen Ave, BROKEN ARROW |
| State: | OK |
| Postal Code: | 740124859 |
| Phone Number: | 9187649300 |
| Fax Number: | 9187649275 |
| NPI Enumeration Date: | 04/06/2015 |
| NPI Last Update Date: | 10/27/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 116446 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |