=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720161698
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLEY SUZANNE CRAGG ROZAS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 01/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4140 W MEMORIAL RD STE 107
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73120-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-936-5888
-----------------------------------------------------
Fax | 405-936-5899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4140 W MEMORIAL RD STE 107
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73120-8300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-936-5888
-----------------------------------------------------
Fax | 405-936-5899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 1030
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------