Provider Demographics
NPI:1477825164
Name:CHEATWOOD, JEREMY S (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:CHEATWOOD
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 1:13100 N WESTERN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-1431
Mailing Address - Country:US
Mailing Address - Phone:405-418-4500
Mailing Address - Fax:405-418-4501
Practice Address - Street 1:13100 N WESTERN AVE STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-1431
Practice Address - Country:US
Practice Address - Phone:405-418-4500
Practice Address - Fax:405-418-4501
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant