Healthcare Provider Details

I. General information

NPI: 1003352543
Provider Name (Legal Business Name): ANNE CLAIRE EDMONDS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNE CLAIRE MIX PA-C

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 S YALE AVE STE 1200
TULSA OK
74136-8313
US

IV. Provider business mailing address

6600 S YALE AVE STE 1200
TULSA OK
74136-3361
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-3376
  • Fax: 918-502-3375
Mailing address:
  • Phone: 918-488-6045
  • Fax: 918-488-6098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2911
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: