Healthcare Provider Details

I. General information

NPI: 1720806086
Provider Name (Legal Business Name): BIANCA RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2024
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SHARE DR
ALVA OK
73717-3613
US

IV. Provider business mailing address

1736 CHERRY ST
ALVA OK
73717-1837
US

V. Phone/Fax

Practice location:
  • Phone: 580-430-3366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5698
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: