Provider Demographics
NPI:1346796604
Name:HEALTHCARE STAT OF NEWCASTLE LLC
Entity Type:Organization
Organization Name:HEALTHCARE STAT OF NEWCASTLE LLC
Other - Org Name:HEALTHCARE STAT OF NEWCASTLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:405-792-0200
Mailing Address - Street 1:PO BOX 5908
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-5908
Mailing Address - Country:US
Mailing Address - Phone:405-659-5656
Mailing Address - Fax:405-701-5421
Practice Address - Street 1:2120 N MAIN ST SUITE B
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:OK
Practice Address - Zip Code:73065
Practice Address - Country:US
Practice Address - Phone:405-792-0200
Practice Address - Fax:405-701-5421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK68442363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty