Provider Demographics
NPI:1164584868
Name:RAU, JENNIFER L (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:RAU
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:PO BOX 22063
Mailing Address - Street 2:DEPT 0491
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-2063
Mailing Address - Country:US
Mailing Address - Phone:405-751-4554
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:8509 S FIR AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-1220
Practice Address - Country:US
Practice Address - Phone:918-286-0412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1566363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200108800AMedicaid
OKOK400428Medicare PIN
OK242714303Medicare PIN
OK242714304Medicare PIN