Provider Demographics
NPI:1245945153
Name:AZZO, JEANINE (PA-C)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:AZZO
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 1:1616 S MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0304
Mailing Address - Country:US
Mailing Address - Phone:405-256-0501
Mailing Address - Fax:
Practice Address - Street 1:4630 LONG PRAIRIE RD STE 210
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1964
Practice Address - Country:US
Practice Address - Phone:469-495-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4891363A00000X
TXPA18155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant