Provider Demographics
NPI:1760561351
Name:PAUL, JOHN THOMAS (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:PAUL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 12TH AVE NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1206
Mailing Address - Country:US
Mailing Address - Phone:580-223-5180
Mailing Address - Fax:580-223-5184
Practice Address - Street 1:2002 12TH AVE NW
Practice Address - Street 2:SUITE B
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1206
Practice Address - Country:US
Practice Address - Phone:580-223-5180
Practice Address - Fax:580-223-5184
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2395363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU40889Medicare UPIN