Provider Demographics
NPI:1336145010
Name:MCCAMPBELL, MARY A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MCCAMPBELL
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 1:6839 S CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3402
Mailing Address - Country:US
Mailing Address - Phone:832-283-7391
Mailing Address - Fax:
Practice Address - Street 1:6839 S CANTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3402
Practice Address - Country:US
Practice Address - Phone:918-494-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05050363AM0700X
OK1219363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y3325OtherBCBS
P91551Medicare UPIN
TX8Y3325OtherBCBS
TX8K1692Medicare PIN