Healthcare Provider Details

I. General information

NPI: 1861034779
Provider Name (Legal Business Name): SHAWNEE MEDICAL CENTER CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 W WRANGLER BLVD STE C
SEMINOLE OK
74868-1900
US

IV. Provider business mailing address

2403 W WRANGLER BLVD STE C
SEMINOLE OK
74868-1900
US

V. Phone/Fax

Practice location:
  • Phone: 405-716-3070
  • Fax: 405-716-3069
Mailing address:
  • Phone: 405-716-3070
  • Fax: 405-716-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL L PENA
Title or Position: PROVIDER ENROLLMENT/INS CREDENTIAL
Credential:
Phone: 405-272-7452