MEDICARE: TARA GLEAVES P.A.

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	1727	OK

General Provider Information

NPI Number	:	1801061353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA GLEAVES P.A.

Provider Business Mailing Address
First Line	:	3500 S WESTERN AVE
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 AVE
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	:	04/25/2008
Last Update Date	:	09/04/2013

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