Healthcare Provider Details

I. General information

NPI: 1194759134
Provider Name (Legal Business Name): JANET LESLIE PLAXICO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E. ROSS BYPASS ROAD
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

PO BOX 1008
TAHLEQUAH OK
74465-1008
US

V. Phone/Fax

Practice location:
  • Phone: 918-207-0991
  • Fax: 918-456-7570
Mailing address:
  • Phone: 918-207-0991
  • Fax: 918-456-7570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA772
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number772
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier100094770A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: