Provider Demographics
NPI:1235152737
Name:SHANDY, TONJA (PA- C)
Entity Type:Individual
Prefix:
First Name:TONJA
Middle Name:
Last Name:SHANDY
Suffix:
Gender:F
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 1:1801 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-3942
Mailing Address - Country:US
Mailing Address - Phone:918-756-4333
Mailing Address - Fax:918-759-2081
Practice Address - Street 1:1401 N 4TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-1806
Practice Address - Country:US
Practice Address - Phone:405-527-5400
Practice Address - Fax:405-527-7332
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS76931Medicare UPIN