Provider Demographics
NPI:1629645015
Name:ROBERTSON, DESTINY (PA-C)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:
Other - Last Name:WHEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10812 NW 28TH ST
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-1827
Mailing Address - Country:US
Mailing Address - Phone:405-635-5612
Mailing Address - Fax:
Practice Address - Street 1:7301 N COMANCHE AVE
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-6646
Practice Address - Country:US
Practice Address - Phone:405-728-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4596363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical