Provider Demographics
NPI:1215005244
Name:STREET, WILLIE J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:J
Last Name:STREET
Suffix:
Gender:M
Credentials:PA-C
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 532
Mailing Address - Street 2:
Mailing Address - City:TONKAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74653-0532
Mailing Address - Country:US
Mailing Address - Phone:580-628-4800
Mailing Address - Fax:
Practice Address - Street 1:600 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:TONKAWA
Practice Address - State:OK
Practice Address - Zip Code:74653-3545
Practice Address - Country:US
Practice Address - Phone:580-628-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK631363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100101960GMedicaid
OKPO1471Medicare UPIN
OK100101960GMedicaid