Provider Demographics
NPI:1871397422
Name:WAHL, NIKOLAS SHANE (RN, BSN)
Entity type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:SHANE
Last Name:WAHL
Suffix:
Gender:
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N MINGO RD TRLR 106
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74116-5639
Mailing Address - Country:US
Mailing Address - Phone:405-420-2219
Mailing Address - Fax:
Practice Address - Street 1:801 N MINGO RD TRLR 106
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74116-5639
Practice Address - Country:US
Practice Address - Phone:405-420-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OKR0128863163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program