Provider Demographics
NPI:1023071156
Name:HARRYMAN, SANDRA KAY (PA)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:KAY
Last Name:HARRYMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3400 S.E. FRANK PHILLIPS
Mailing Address - Street 2:STE 502
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2495
Mailing Address - Country:US
Mailing Address - Phone:918-331-2577
Mailing Address - Fax:918-331-2513
Practice Address - Street 1:3400 S.E. FRANK PHILLIPS
Practice Address - Street 2:STE 502
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2495
Practice Address - Country:US
Practice Address - Phone:918-331-2577
Practice Address - Fax:918-331-2513
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK989363A00000X
KS1500323363A00000X
KS15-00323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100193360AMedicaid
KS10003240CMedicaid
OK100193360AMedicaid
KS10003240CMedicaid