Provider Demographics
NPI:1376705806
Name:MEDLEY, SHANNON (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MEDLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 N MONTE VISTA
Mailing Address - Street 2:SUITE A
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4675
Mailing Address - Country:US
Mailing Address - Phone:580-436-7101
Mailing Address - Fax:580-436-4447
Practice Address - Street 1:1208 W 15TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3001
Practice Address - Country:US
Practice Address - Phone:405-340-2100
Practice Address - Fax:405-340-1184
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1614363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical