Provider Demographics
NPI:1609029644
Name:HEALTHCARE STAT
Entity Type:Organization
Organization Name:HEALTHCARE STAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:405-485-9588
Mailing Address - Street 1:PO BOX 1126
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1126
Mailing Address - Country:US
Mailing Address - Phone:405-659-5656
Mailing Address - Fax:405-701-5421
Practice Address - Street 1:1619 S 4TH ST
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-5860
Practice Address - Country:US
Practice Address - Phone:405-224-6700
Practice Address - Fax:405-224-6707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0068442261QP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226680AMedicaid
OK200226680AMedicaid