Healthcare Provider Details

I. General information

NPI: 1831140383
Provider Name (Legal Business Name): FREDRIC A WEST P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 BUFFINGTON RD
WESTVILLE OK
74965-7011
US

IV. Provider business mailing address

PO BOX 408
WESTVILLE OK
74965-0408
US

V. Phone/Fax

Practice location:
  • Phone: 918-723-3997
  • Fax: 918-723-3889
Mailing address:
  • Phone: 918-723-5456
  • Fax: 918-723-4080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA238
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1075
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: