Provider Demographics
NPI:1225262892
Name:WELTON, HEATH BRANDON (PAC)
Entity Type:Individual
Prefix:
First Name:HEATH
Middle Name:BRANDON
Last Name:WELTON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13616 E 103RD ST N
Mailing Address - Street 2:STE A
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4586
Mailing Address - Country:US
Mailing Address - Phone:918-274-8555
Mailing Address - Fax:918-274-8556
Practice Address - Street 1:13616 E 103RD ST N
Practice Address - Street 2:STE A
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4586
Practice Address - Country:US
Practice Address - Phone:918-274-8555
Practice Address - Fax:918-274-8556
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200243070AMedicaid
OK200243070AMedicaid