Provider Demographics
NPI:1578567590
Name:WOODALL, ANNETTE (PAC)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:WOODALL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:HIXSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 274
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-1515
Mailing Address - Fax:405-271-1001
Practice Address - Street 1:825 NE 10TH ST
Practice Address - Street 2:OUPB 4500
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5417
Practice Address - Country:US
Practice Address - Phone:405-271-5789
Practice Address - Fax:405-271-1001
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK402857Medicare PIN