MEDICARE: MCKINLEY BOATNER 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
1	363AM0700X	Medical Physician Assistant	578	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	578	OTHER	OK	PA LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508840695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKINLEY BOATNER PA

Provider Business Mailing Address
First Line	:	PO BOX 30589
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73140-3589
Country	:	US
Telephone Number	:	405-769-3301
Fax Number	:	405-769-9685

Provider Business Practice Location Address
First Line	:	1901 SPRINGLAKE DR
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73111-5201
Country	:	US
Telephone Number	:	405-521-8486
Fax Number	:	405-521-8496

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

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	10/30/2019

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Directions to “ MCKINLEY BOATNER PA” Practice Location

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