Healthcare Provider Details

I. General information

NPI: 1982624292
Provider Name (Legal Business Name): OWASSO PEDIATRIC AND ADOLESCENT MEDICINE, P.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12455 E 100TH ST N SUITE 280
OWASSO OK
74055-4600
US

IV. Provider business mailing address

12455 E 100TH ST N SUITE 280
OWASSO OK
74055-4600
US

V. Phone/Fax

Practice location:
  • Phone: 918-274-9700
  • Fax:
Mailing address:
  • Phone: 918-274-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AARON HENLEY
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 918-274-9700