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NPI Code Detail

MEDICARE: JOE BYNUM BOURLAND PA

MEDICARE: JOE BYNUM BOURLAND PA
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
1363AM0700XMedical Physician Assistant899OK
2363AS0400XSurgical Physician Assistant899OK
3363A00000XPhysician Assistant899OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1899OTHEROKMEDICAL LICENSE

General Provider Information

NPI Number : 1306827373
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOE BYNUM BOURLAND PA
Provider Business Mailing Address
First Line : 11521 S WESTERN AVE STE B
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73170-5883
Country : US
Telephone Number : 405-676-9125
Fax Number : 405-400-8772
Provider Business Practice Location Address
First Line : 1140 S DOUGLAS BLVD
Second Line :
City : MIDWEST CITY
State : OK
Zip : 73130-5236
Country : US
Telephone Number : 405-733-8000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/08/2005
Last Update Date : 10/04/2023

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