Provider Demographics
NPI:1659595023
Name:MILES, WENDELL EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:EDWARD
Last Name:MILES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JOSEPH HARP CORRECTIONAL CENTER / MED
Mailing Address - Street 2:P.O. BOX 548
Mailing Address - City:LEXINGTON
Mailing Address - State:OK
Mailing Address - Zip Code:73051-0548
Mailing Address - Country:US
Mailing Address - Phone:405-527-5593
Mailing Address - Fax:
Practice Address - Street 1:JOSEPH HARP CORRECTIONAL CENTER
Practice Address - Street 2:16161 MOFFET ROAD
Practice Address - City:LEXINGTON
Practice Address - State:OK
Practice Address - Zip Code:73051-0548
Practice Address - Country:US
Practice Address - Phone:405-527-5593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant