Provider Demographics
NPI:1164597860
Name:SANDERS, BILLY GRANT (PA)
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:GRANT
Last Name:SANDERS
Suffix:
Gender:M
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 10
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-0010
Mailing Address - Country:US
Mailing Address - Phone:405-390-9600
Mailing Address - Fax:405-390-9400
Practice Address - Street 1:15809 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8428
Practice Address - Country:US
Practice Address - Phone:405-390-9600
Practice Address - Fax:405-390-9400
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1561363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK400905OtherMEDICARE INDIVIDUAL PTAN
OK200100040AMedicaid
900522085OtherMEDICARE GROUP PTAN - CARY CARPENTER MD PC DBA CHOCTAW FAMILY MEDICINE