Provider Demographics
NPI:1134109457
Name:WAGES, DEANA M (PA)
Entity Type:Individual
Prefix:
First Name:DEANA
Middle Name:M
Last Name:WAGES
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 1:2417 COUNTY ROAD 1263 STE 100
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-3123
Mailing Address - Country:US
Mailing Address - Phone:405-274-5551
Mailing Address - Fax:
Practice Address - Street 1:2417 COUNTY ROAD 1263 STE 100
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010-3123
Practice Address - Country:US
Practice Address - Phone:405-274-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ50972Medicare UPIN