Provider Demographics
NPI:1831140383
Name:WEST, FREDRIC A (PA)
Entity Type:Individual
Prefix:MR
First Name:FREDRIC
Middle Name:A
Last Name:WEST
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74965-0408
Mailing Address - Country:US
Mailing Address - Phone:918-723-5456
Mailing Address - Fax:918-723-4080
Practice Address - Street 1:761 BUFFINGTON RD
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:OK
Practice Address - Zip Code:74965-7011
Practice Address - Country:US
Practice Address - Phone:918-723-3997
Practice Address - Fax:918-723-3889
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA238363A00000X
OK1075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100074610AMedicaid
OK100074610DMedicaid
AR50412P096Medicare ID - Type Unspecified
OK100074610DMedicaid
P37358Medicare UPIN