Provider Demographics
NPI:1760805329
Name:DOUGLAS, SAURA C (PA-C)
Entity Type:Individual
Prefix:
First Name:SAURA
Middle Name:C
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAURA
Other - Middle Name:
Other - Last Name:SHANAKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4022
Mailing Address - Country:US
Mailing Address - Phone:918-579-3130
Mailing Address - Fax:918-579-3139
Practice Address - Street 1:1145 S UTICA AVE STE 202
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4022
Practice Address - Country:US
Practice Address - Phone:918-579-3130
Practice Address - Fax:918-579-3139
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2372363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200550180AMedicaid