Healthcare Provider Details

I. General information

NPI: 1780689943
Provider Name (Legal Business Name): ANGELA K SMITH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6613 N MERIDIAN AVE
OKLAHOMA CITY OK
73116-1423
US

IV. Provider business mailing address

930 N FLOOD AVE
NORMAN OK
73069-7642
US

V. Phone/Fax

Practice location:
  • Phone: 405-603-8450
  • Fax: 405-603-8455
Mailing address:
  • Phone: 405-321-3719
  • Fax: 405-364-3209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1106
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: