Provider Demographics
NPI:1821482811
Name:GARRETT, STEPHANIE JANE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JANE
Last Name:GARRETT
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 1:505 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTER
Mailing Address - State:OK
Mailing Address - Zip Code:74454-1015
Mailing Address - Country:US
Mailing Address - Phone:918-483-0111
Mailing Address - Fax:918-483-4174
Practice Address - Street 1:505 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTER
Practice Address - State:OK
Practice Address - Zip Code:74454-1015
Practice Address - Country:US
Practice Address - Phone:918-483-0111
Practice Address - Fax:918-483-4174
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant