Provider Demographics
NPI:1780689943
Name:SMITH, ANGELA K (PAC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 N FLOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-7642
Mailing Address - Country:US
Mailing Address - Phone:405-321-3719
Mailing Address - Fax:405-364-3209
Practice Address - Street 1:6613 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1423
Practice Address - Country:US
Practice Address - Phone:405-603-8450
Practice Address - Fax:405-603-8455
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200042650AMedicaid
Q29844Medicare UPIN
OK200042650AMedicaid