Provider Demographics
NPI:1417598293
Name:LEGG, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:LEGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 336
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:OK
Mailing Address - Zip Code:73834-0336
Mailing Address - Country:US
Mailing Address - Phone:520-780-3920
Mailing Address - Fax:
Practice Address - Street 1:7TH & OKLAHOMA STE 5
Practice Address - Street 2:
Practice Address - City:LAVERNE
Practice Address - State:OK
Practice Address - Zip Code:73848-0987
Practice Address - Country:US
Practice Address - Phone:580-921-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3169363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200892080AMedicaid