Provider Demographics
NPI:1083685630
Name:CHRISTIE, GAVIN C (PA)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:C
Last Name:CHRISTIE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-552-0401
Mailing Address - Fax:405-848-3210
Practice Address - Street 1:3366 NW EXPRESSWAY STE 250
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4427
Practice Address - Country:US
Practice Address - Phone:405-552-0401
Practice Address - Fax:405-848-3210
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100167880AMedicaid
OKP51722Medicare UPIN
249621405Medicare PIN
OK100167880AMedicaid