Provider Demographics
NPI:1578100566
Name:SALLEE, BETHANY ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ROSE
Last Name:SALLEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:GUFFY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16495 TIMBERS DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73165-6530
Mailing Address - Country:US
Mailing Address - Phone:405-203-8802
Mailing Address - Fax:
Practice Address - Street 1:808 WALL ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6302
Practice Address - Country:US
Practice Address - Phone:405-977-4321
Practice Address - Fax:405-977-0521
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200884310AMedicaid
OK909248OtherMEDICARE PTAN