Healthcare Provider Details

I. General information

NPI: 1134109457
Provider Name (Legal Business Name): DEANA M. WAGES P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2417 COUNTY ROAD 1263 STE 100
BLANCHARD OK
73010-3123
US

IV. Provider business mailing address

2417 COUNTY ROAD 1263 STE 100
BLANCHARD OK
73010-3123
US

V. Phone/Fax

Practice location:
  • Phone: 405-274-5551
  • Fax:
Mailing address:
  • Phone: 405-274-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1451
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: