Provider Demographics
NPI:1972648038
Name:ODOM, AMANDA KAYE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:KAYE
Last Name:ODOM
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 1:900 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5420
Mailing Address - Country:US
Mailing Address - Phone:405-271-2058
Mailing Address - Fax:
Practice Address - Street 1:900 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5420
Practice Address - Country:US
Practice Address - Phone:405-271-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA 1017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1357924680Medicaid