Provider Demographics
NPI:1114188232
Name:GENTRY, CASSANDRA (PA)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 SW 30TH CT
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2887
Mailing Address - Country:US
Mailing Address - Phone:405-378-2727
Mailing Address - Fax:405-378-2776
Practice Address - Street 1:1105 SW 30TH CT
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2887
Practice Address - Country:US
Practice Address - Phone:405-378-2727
Practice Address - Fax:405-378-2776
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1515363AM0700X
1515363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical