Healthcare Provider Details

I. General information

NPI: 1699559633
Provider Name (Legal Business Name): BLAINE MATTHEW FIFE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 NW EXPRESSWAY STE 720
OKLAHOMA CITY OK
73112-4416
US

IV. Provider business mailing address

3001 QUAIL SPRINGS PKWY FL 5
OKLAHOMA CITY OK
73134-2640
US

V. Phone/Fax

Practice location:
  • Phone: 405-727-3000
  • Fax: 405-727-3007
Mailing address:
  • Phone: 405-727-3000
  • Fax: 405-727-3007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5723
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: