Healthcare Provider Details

I. General information

NPI: 1508649310
Provider Name (Legal Business Name): ERICA PONCE-DOUGHERTY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 PARKWAY COMMONS DR STE 100
OKLAHOMA CITY OK
73134-6036
US

IV. Provider business mailing address

14100 PARKWAY COMMONS DR STE 100
OKLAHOMA CITY OK
73134-6036
US

V. Phone/Fax

Practice location:
  • Phone: 405-748-3300
  • Fax: 405-749-1671
Mailing address:
  • Phone: 405-748-3300
  • Fax: 405-749-1671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1508649310
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1508649310
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1508649310
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: