Healthcare Provider Details

I. General information

NPI: 1952368961
Provider Name (Legal Business Name): SALLY MARIE ROARK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W TECUMSEH RD STE 101
NORMAN OK
73072-1810
US

IV. Provider business mailing address

3400 W TECUMSEH RD STE 101
NORMAN OK
73072-1810
US

V. Phone/Fax

Practice location:
  • Phone: 405-360-6764
  • Fax: 405-360-6769
Mailing address:
  • Phone: 405-360-6764
  • Fax: 405-360-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1239
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: