Healthcare Provider Details

I. General information

NPI: 1306331921
Provider Name (Legal Business Name): BLAIR TERRY PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 S WALKER AVE BLDG A
OKLAHOMA CITY OK
73139-9475
US

IV. Provider business mailing address

8100 S WALKER AVE BLDG A
OKLAHOMA CITY OK
73139-9475
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-4468
  • Fax: 405-632-0436
Mailing address:
  • Phone: 405-632-4468
  • Fax: 405-632-0436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2922
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: