Provider Demographics
NPI:1417971276
Name:BIRCH, JENNIFER JOY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOY
Last Name:BIRCH
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 1:6613 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1423
Mailing Address - Country:US
Mailing Address - Phone:405-603-8450
Mailing Address - Fax:405-603-8455
Practice Address - Street 1:3817 NW EXPRESSWAY
Practice Address - Street 2:STE. 710
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-1489
Practice Address - Country:US
Practice Address - Phone:405-943-8924
Practice Address - Fax:405-943-8967
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAPA1421363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200052300AMedicaid
OK800523304Medicare ID - Type UnspecifiedRIAZ SIRAJUDDIN
OKOK401543Medicare PIN
OK200052300AMedicaid