Provider Demographics
NPI:1225308810
Name:WHEELER, RUSSELL ADAM (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ADAM
Last Name:WHEELER
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 1:4221 S WESTERN AVE
Mailing Address - Street 2:SUITE 5000
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-3447
Mailing Address - Country:US
Mailing Address - Phone:405-644-5165
Mailing Address - Fax:
Practice Address - Street 1:4221 S WESTERN AVE
Practice Address - Street 2:SUITE 5000
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3447
Practice Address - Country:US
Practice Address - Phone:405-644-5165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant