MEDICARE: ANGELA DIANE BARTLOW 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	363AM0700X	Medical Physician Assistant	PA1065	OK

General Provider Information

NPI Number	:	1134175912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA DIANE BARTLOW PA-C

Provider Business Mailing Address
First Line	:	PO BOX 900
Second Line	:	20826 W. MAIN
City	:	HARRAH
State	:	OK
Zip	:	73045-0900
Country	:	US
Telephone Number	:	405-454-2404
Fax Number	:	405-454-6371

Provider Business Practice Location Address
First Line	:	20826 MAIN ST
Second Line	:
City	:	HARRAH
State	:	OK
Zip	:	73045-9756
Country	:	US
Telephone Number	:	405-454-2404
Fax Number	:	405-454-6371

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

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	08/08/2016

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