Healthcare Provider Details

I. General information

NPI: 1265661995
Provider Name (Legal Business Name): ANGELA DAWN CUSHING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 W 6TH AVE
STILLWATER OK
74074-4202
US

IV. Provider business mailing address

6600 S YALE AVE SUITE 1400
TULSA OK
74136-3347
US

V. Phone/Fax

Practice location:
  • Phone: 405-743-7300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2142
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPENDING
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: