Provider Demographics
NPI:1558136549
Name:JIMENEZ, SUSANA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14024 QUAIL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1006
Mailing Address - Country:US
Mailing Address - Phone:405-419-5610
Mailing Address - Fax:405-419-5471
Practice Address - Street 1:3115 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7901
Practice Address - Country:US
Practice Address - Phone:405-419-5610
Practice Address - Fax:405-419-5471
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant