Provider Demographics
NPI:1477039501
Name:VORWALD, BROCK WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:WILLIAM
Last Name:VORWALD
Suffix:
Gender:M
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 1:1600 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6357
Mailing Address - Country:US
Mailing Address - Phone:405-330-2362
Mailing Address - Fax:405-330-2363
Practice Address - Street 1:1600 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6357
Practice Address - Country:US
Practice Address - Phone:405-330-2362
Practice Address - Fax:405-330-2363
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA3000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant