Provider Demographics
NPI:1417911181
Name:SHEAMAN, MARK ALAN (PAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:SHEAMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 12TH AVE NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1206
Mailing Address - Country:US
Mailing Address - Phone:580-223-4795
Mailing Address - Fax:580-223-5184
Practice Address - Street 1:2002 12TH AVE NW
Practice Address - Street 2:SUITE B
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1206
Practice Address - Country:US
Practice Address - Phone:580-223-4795
Practice Address - Fax:580-223-5184
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPA004841Medicare ID - Type Unspecified
OKR10970Medicare UPIN