Provider Demographics
NPI:1265516827
Name:WINK, CAROL DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:DIANE
Last Name:WINK
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 1:402 W MORROW RD
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-6549
Mailing Address - Country:US
Mailing Address - Phone:918-295-1328
Mailing Address - Fax:918-403-6313
Practice Address - Street 1:402 W MORROW RD
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-6549
Practice Address - Country:US
Practice Address - Phone:918-295-1328
Practice Address - Fax:918-403-6313
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1147363A00000X
OK1455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P47852Medicare UPIN