Provider Demographics
NPI:1790762771
Name:VIEFHAUS, MARTY (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:
Last Name:VIEFHAUS
Suffix:
Gender:F
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 1:1001 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2847
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:580-924-7215
Practice Address - Street 1:1600 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2128
Practice Address - Country:US
Practice Address - Phone:580-920-2100
Practice Address - Fax:580-924-7215
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP35872Medicare UPIN