Provider Demographics
NPI:1083613822
Name:MONROE, JOE RANDALL (PA)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:RANDALL
Last Name:MONROE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3835
Mailing Address - Country:US
Mailing Address - Phone:405-636-1506
Mailing Address - Fax:405-636-1511
Practice Address - Street 1:4805 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3835
Practice Address - Country:US
Practice Address - Phone:405-636-1506
Practice Address - Fax:405-636-1511
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P49865Medicare UPIN
OK241426023Medicare PIN