Provider Demographics
NPI:1003154725
Name:BOHANNON, QUINTON TY (PA-C)
Entity Type:Individual
Prefix:
First Name:QUINTON
Middle Name:TY
Last Name:BOHANNON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-2827
Mailing Address - Country:US
Mailing Address - Phone:580-927-2334
Mailing Address - Fax:
Practice Address - Street 1:108 W OHIO AVE
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-2827
Practice Address - Country:US
Practice Address - Phone:580-927-2334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2239363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical