Healthcare Provider Details

I. General information

NPI: 1689626210
Provider Name (Legal Business Name): SHEILA R. GOFORTH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N KANSAS ST
WEATHERFORD OK
73096-5443
US

IV. Provider business mailing address

2411 SW 122ND ST
OKLAHOMA CITY OK
73170-4844
US

V. Phone/Fax

Practice location:
  • Phone: 580-772-5551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number897
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number897
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: