Provider Demographics
NPI:1992193676
Name:BETHEA, SAMUEL ISAAC (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ISAAC
Last Name:BETHEA
Suffix:
Gender:M
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 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-927-3226
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:1071 W BLUE STARR DR STE 105
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-2869
Practice Address - Country:US
Practice Address - Phone:918-361-0600
Practice Address - Fax:918-927-3201
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200570050AMedicaid
OK2431OtherOKLAHOMA BOARD OF MEDICAL LICENSURE AND SUPERVISION