Healthcare Provider Details

I. General information

NPI: 1134175912
Provider Name (Legal Business Name): ANGELA DIANE BARTLOW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20826 MAIN ST
HARRAH OK
73045-9756
US

IV. Provider business mailing address

PO BOX 900 20826 W. MAIN
HARRAH OK
73045-0900
US

V. Phone/Fax

Practice location:
  • Phone: 405-454-2404
  • Fax: 405-454-6371
Mailing address:
  • Phone: 405-454-2404
  • Fax: 405-454-6371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1065
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: