Provider Demographics
NPI:1184675464
Name:GHAN, SHERYL EVONE (DO)
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:EVONE
Last Name:GHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5831 EUPER LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3239
Mailing Address - Country:US
Mailing Address - Phone:479-629-6125
Mailing Address - Fax:
Practice Address - Street 1:301 J T STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9302
Practice Address - Country:US
Practice Address - Phone:918-775-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0744208000000X
OK3197208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129484001Medicaid
8ED012OtherMCB-SALLISAW
OK1203197Medicaid
8ED012OtherMCB-SALLISAW