MEDICARE: GREGORY W DINWIDDIE PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1037	OK

General Provider Information

NPI Number	:	1578567848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY W DINWIDDIE PAC

Provider Business Mailing Address
First Line	:	3433 NW 56TH ST
Second Line	:	STE 760
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4455
Country	:	US
Telephone Number	:	405-951-4345
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4418
Country	:	US
Telephone Number	:	405-949-3349
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2005
Last Update Date	:	07/21/2022

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