Healthcare Provider Details

I. General information

NPI: 1548327653
Provider Name (Legal Business Name): MERRY MATHEW THENMADATHIL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MERRY MATHEW

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BROADWAY EXT STE 200
OKLAHOMA CITY OK
73114-6323
US

IV. Provider business mailing address

9900 BROADWAY EXT STE 200
OKLAHOMA CITY OK
73114-6323
US

V. Phone/Fax

Practice location:
  • Phone: 405-608-8833
  • Fax: 405-608-8188
Mailing address:
  • Phone: 405-608-8833
  • Fax: 405-608-8188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number011540
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1857
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: