Healthcare Provider Details

I. General information

NPI: 1487626826
Provider Name (Legal Business Name): AMY B RISLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W MEMORIAL RD
OKLAHOMA CITY OK
73120-8304
US

IV. Provider business mailing address

8100 S WALKER AVE BLDG A
OKLAHOMA CITY OK
73139-9404
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-2323
  • Fax: 405-631-9315
Mailing address:
  • Phone: 405-752-3162
  • Fax: 405-936-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1111
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: