Healthcare Provider Details

I. General information

NPI: 1164597860
Provider Name (Legal Business Name): BILLY GRANT SANDERS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 09/21/2025
Certification Date: 09/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15679 NE 23RD ST
CHOCTAW OK
73020-8592
US

IV. Provider business mailing address

PO BOX 10
CHOCTAW OK
73020-0010
US

V. Phone/Fax

Practice location:
  • Phone: 405-390-9600
  • Fax:
Mailing address:
  • Phone: 405-390-9600
  • Fax: 405-390-9400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1561
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: