Provider Demographics
NPI:1831472620
Name:PONCA CITY PRIMARY CARE LLC
Entity Type:Organization
Organization Name:PONCA CITY PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:AGHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-762-6100
Mailing Address - Street 1:417 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1923
Mailing Address - Country:US
Mailing Address - Phone:580-762-6100
Mailing Address - Fax:580-762-6104
Practice Address - Street 1:417 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1923
Practice Address - Country:US
Practice Address - Phone:580-762-6100
Practice Address - Fax:580-762-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0050756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty