Healthcare Provider Details

I. General information

NPI: 1477825164
Provider Name (Legal Business Name): JEREMY S CHEATWOOD PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 N WESTERN AVE STE 200
OKLAHOMA CITY OK
73114-1431
US

IV. Provider business mailing address

13100 N WESTERN AVE STE 200
OKLAHOMA CITY OK
73114-1431
US

V. Phone/Fax

Practice location:
  • Phone: 405-418-4500
  • Fax: 405-418-4501
Mailing address:
  • Phone: 405-418-4500
  • Fax: 405-418-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2110
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: