=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033675954
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGEL VILCHIS PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2019
-----------------------------------------------------
Last Update Date | 02/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1841 BELLE ISLE BLVD STE L
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73118-4226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-445-7504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 175
-----------------------------------------------------
City | BROMIDE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74530-0175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-380-7627
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2799
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------