Provider Demographics
NPI:1023005790
Name:TODD, HEATHER MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:TODD
Suffix:
Gender:F
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 1:7919 MID AMERICA BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-6610
Mailing Address - Country:US
Mailing Address - Phone:405-855-6204
Mailing Address - Fax:405-456-7524
Practice Address - Street 1:7919 MID AMERICA BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135
Practice Address - Country:US
Practice Address - Phone:405-855-6204
Practice Address - Fax:405-456-7524
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100028600BMedicaid
OK100028600BMedicaid
OKMM0756936OtherDEA NUMBER
OK100028600BMedicaid