MEDICARE: BERNADETTE MARIE DUBE PA

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	648	OK

General Provider Information

NPI Number	:	1720015241
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERNADETTE MARIE DUBE PA

Provider Business Mailing Address
First Line	:	9600 BROADWAY EXT
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-7408
Country	:	US
Telephone Number	:	405-230-9000
Fax Number	:	405-230-9157

Provider Business Practice Location Address
First Line	:	4901 W RENO AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73127-6346
Country	:	US
Telephone Number	:	405-230-9250
Fax Number	:	405-943-0742

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	08/09/2019

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