Provider Demographics
NPI:1922136480
Name:F.G.M.A. ,LLC.
Entity Type:Organization
Organization Name:F.G.M.A. ,LLC.
Other - Org Name:FAMILY AND GERIATRIC MEDICAL ASSOCIATES
Other - Org Type:Other Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:GRANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:405-917-7590
Mailing Address - Street 1:5622 N PORTLAND AVE
Mailing Address - Street 2:#102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2096
Mailing Address - Country:US
Mailing Address - Phone:405-917-7590
Mailing Address - Fax:405-917-7595
Practice Address - Street 1:5622 N PORTLAND AVE
Practice Address - Street 2:#102
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2096
Practice Address - Country:US
Practice Address - Phone:405-917-7590
Practice Address - Fax:405-917-7595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0028064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100216830DMedicaid
OKR0028064OtherSUSAN GRANDLE LIC #
OKR0028064OtherSUSAN GRANDLE LIC #
OKP02494Medicare UPIN