Provider Demographics
NPI:1356347629
Name:CAMPBELL, LOUIE (PA)
Entity type:Individual
Prefix:
First Name:LOUIE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:580-233-9012
Mailing Address - Fax:580-249-4269
Practice Address - Street 1:1805 W GARRIOTT RD
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5526
Practice Address - Country:US
Practice Address - Phone:580-233-9012
Practice Address - Fax:580-249-4269
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK649363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200012180AMedicaid
OK200012180AMedicaid
OK248327302Medicare ID - Type Unspecified