Healthcare Provider Details

I. General information

NPI: 1710125018
Provider Name (Legal Business Name): MIKE LYNN SANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 BROADWAY EXT
OKLAHOMA CITY OK
73114-7408
US

IV. Provider business mailing address

9600 BROADWAY EXT
OKLAHOMA CITY OK
73114-7408
US

V. Phone/Fax

Practice location:
  • Phone: 405-230-9000
  • Fax: 405-230-9157
Mailing address:
  • Phone: 405-230-9000
  • Fax: 405-230-9157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1808
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: