Provider Demographics
NPI:1306827373
Name:BOURLAND, JOE BYNUM (PA)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:BYNUM
Last Name:BOURLAND
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11521 S WESTERN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-5883
Mailing Address - Country:US
Mailing Address - Phone:405-676-9125
Mailing Address - Fax:405-400-8772
Practice Address - Street 1:1140 S DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5236
Practice Address - Country:US
Practice Address - Phone:405-733-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK899363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK899OtherMEDICAL LICENSE
OK100140830AMedicaid
OKOKAAA3341Medicare PIN