Provider Demographics
NPI:1073753638
Name:FERGUSON, CARLY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:
Last Name:FERGUSON
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 1:3400 W TECUMSEH RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1810
Mailing Address - Country:US
Mailing Address - Phone:405-360-6764
Mailing Address - Fax:405-360-6769
Practice Address - Street 1:3400 W TECUMSEH RD STE 101
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1810
Practice Address - Country:US
Practice Address - Phone:405-360-6764
Practice Address - Fax:405-360-6469
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01744363A00000X
OH50.004349RX363A00000X
OK4708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant