Healthcare Provider Details

I. General information

NPI: 1700877321
Provider Name (Legal Business Name): CATHY LOUISE WELCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 E ROSS BYP SUITE A
TAHLEQUAH OK
74464-4133
US

IV. Provider business mailing address

14449 N 525 RD
TAHLEQUAH OK
74464-0443
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-1234
  • Fax:
Mailing address:
  • Phone: 918-431-1599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA769
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100313470B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier400522239
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerMEDICARE GROUP PTAN
# 3
Identifier200000030A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: