MEDICARE: MRS. SHERYL A GROSS P.A.-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	PA02795	TX
2	363A00000X	Physician Assistant	PA4416	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA02795	OTHER	TX	LICENSE

General Provider Information

NPI Number	:	1366567109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHERYL A GROSS P.A.-C

Provider Business Mailing Address
First Line	:	3500 S. WESTERN
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-2413
Country	:	US
Telephone Number	:	405-632-5565
Fax Number	:	405-632-3538

Provider Business Practice Location Address
First Line	:	3500 S. WESTERN
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-2413
Country	:	US
Telephone Number	:	405-632-5565
Fax Number	:	405-632-3538

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	09/10/2020

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