Provider Demographics
NPI:1013090919
Name:GAVULA, THERESA L (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:GAVULA
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 1:1200 N PHILLIPS AVE
Mailing Address - Street 2:SUITE 10,000
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-4600
Mailing Address - Country:US
Mailing Address - Phone:405-271-4412
Mailing Address - Fax:405-271-3265
Practice Address - Street 1:1200 N PHILLIPS AVE
Practice Address - Street 2:SUITE 14500
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-4600
Practice Address - Country:US
Practice Address - Phone:405-271-5311
Practice Address - Fax:405-271-3767
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1312363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ15247Medicare UPIN