Healthcare Provider Details

I. General information

NPI: 1104131721
Provider Name (Legal Business Name): CENTRAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 POND MEADOW DR
OKLAHOMA CITY OK
73151-9149
US

IV. Provider business mailing address

10701 POND MEADOW DR
OKLAHOMA CITY OK
73151-9149
US

V. Phone/Fax

Practice location:
  • Phone: 405-771-4151
  • Fax: 405-771-4151
Mailing address:
  • Phone: 405-771-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1037
License Number StateOK

VIII. Authorized Official

Name: GREG W DINWIDDIE
Title or Position: PRESIDENT
Credential: PHYSICIAN ASSISTANT
Phone: 405-771-4151