Provider Demographics
NPI:1922077049
Name:CLAY, BAMBI A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BAMBI
Middle Name:A
Last Name:CLAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OK
Mailing Address - Zip Code:74536-0219
Mailing Address - Country:US
Mailing Address - Phone:918-569-4143
Mailing Address - Fax:918-569-7552
Practice Address - Street 1:1020 N LAWSON BOULEVARD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:OK
Practice Address - Zip Code:74536-0219
Practice Address - Country:US
Practice Address - Phone:918-569-4143
Practice Address - Fax:918-569-7552
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK16001343Medicaid
OK16001343Medicaid