Provider Demographics
NPI:1114969037
Name:AUSTIN, STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:AUSTIN
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 1:15221 WILFORD WAY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2650
Mailing Address - Country:US
Mailing Address - Phone:405-812-3108
Mailing Address - Fax:
Practice Address - Street 1:1211 N SHARTEL AVE
Practice Address - Street 2:SUITE 900
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2400
Practice Address - Country:US
Practice Address - Phone:405-235-5331
Practice Address - Fax:405-235-0825
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200074400AMedicaid