Healthcare Provider Details

I. General information

NPI: 1295700425
Provider Name (Legal Business Name): TERESA DESHAWN GREEN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA DESHAWN DREW TERESA HARGROVE

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8422 N 123RD EAST AVE
OWASSO OK
74055-2130
US

IV. Provider business mailing address

8422 N 123RD EAST AVE
OWASSO OK
74055-2130
US

V. Phone/Fax

Practice location:
  • Phone: 918-293-2140
  • Fax: 918-712-7164
Mailing address:
  • Phone: 918-858-4353
  • Fax: 668-246-2942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031082
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003136
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC5-0000491
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2962
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: