Healthcare Provider Details

I. General information

NPI: 1457331076
Provider Name (Legal Business Name): MISTY J HARAWAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 SW 2ND ST
CHECOTAH OK
74426-3602
US

IV. Provider business mailing address

116 SW 2ND ST
CHECOTAH OK
74426-3602
US

V. Phone/Fax

Practice location:
  • Phone: 918-473-2278
  • Fax:
Mailing address:
  • Phone: 918-473-2278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 1113
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: