Provider Demographics
NPI:1235199118
Name:RUSSELL, STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8115 S MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4331
Mailing Address - Country:US
Mailing Address - Phone:918-254-6315
Mailing Address - Fax:918-403-6315
Practice Address - Street 1:8115 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4331
Practice Address - Country:US
Practice Address - Phone:918-254-6315
Practice Address - Fax:918-403-6315
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK932363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100740390AMedicaid
OKOK401313Medicare PIN