MEDICARE: SARAH CLOUGHLY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	51534	CA
2	363A00000X	Physician Assistant	2517	OK

General Provider Information

NPI Number	:	1053721142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH CLOUGHLY PA-C

Provider Business Mailing Address
First Line	:	7807 S WALKER AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-9470
Country	:	US
Telephone Number	:	405-636-0767
Fax Number	:	405-636-0353

Provider Business Practice Location Address
First Line	:	7807 S WALKER AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73139-9470
Country	:	US
Telephone Number	:	405-636-0767
Fax Number	:	405-636-0353

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	09/14/2020

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