Provider Demographics
NPI:1790740769
Name:LATHAM, VICKI C (PA-C)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:C
Last Name:LATHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:ANN
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:608 S HESTER ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4516
Mailing Address - Country:US
Mailing Address - Phone:405-377-8000
Mailing Address - Fax:405-377-8040
Practice Address - Street 1:608 S HESTER ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4516
Practice Address - Country:US
Practice Address - Phone:405-377-8000
Practice Address - Fax:405-377-8040
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK725363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200235260AMedicaid
OK200235260AMedicaid