Provider Demographics
NPI:1528020013
Name:POPP, JODIE L (PA)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:L
Last Name:POPP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 E 13TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4419
Mailing Address - Country:US
Mailing Address - Phone:918-582-6800
Mailing Address - Fax:
Practice Address - Street 1:1809 E 13TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4419
Practice Address - Country:US
Practice Address - Phone:918-582-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ22041Medicare UPIN