Provider Demographics
NPI:1134175912
Name:BARTLOW, ANGELA DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:DIANE
Last Name:BARTLOW
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:PO BOX 900
Mailing Address - Street 2:20826 W. MAIN
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-0900
Mailing Address - Country:US
Mailing Address - Phone:405-454-2404
Mailing Address - Fax:405-454-6371
Practice Address - Street 1:20826 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-9756
Practice Address - Country:US
Practice Address - Phone:405-454-2404
Practice Address - Fax:405-454-6371
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1065363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical