Provider Demographics
NPI:1083687750
Name:GRECO, AMY ELAINE (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELAINE
Last Name:GRECO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:ELAINE
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:820 NW 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-6827
Mailing Address - Country:US
Mailing Address - Phone:405-604-4380
Mailing Address - Fax:
Practice Address - Street 1:5501 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2074
Practice Address - Country:US
Practice Address - Phone:405-604-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100125350AMedicaid
OK243530802Medicare ID - Type Unspecified
OK100125350AMedicaid