Healthcare Provider Details

I. General information

NPI: 1558136549
Provider Name (Legal Business Name): SUSANA JIMENEZ PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2556 COVELL VILLAGE DR STE 120
EDMOND OK
73003-9732
US

IV. Provider business mailing address

16109 BIG CYPRESS DR
EDMOND OK
73013-1707
US

V. Phone/Fax

Practice location:
  • Phone: 405-938-0700
  • Fax: 405-861-8535
Mailing address:
  • Phone: 612-865-8717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5123
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: