Provider Demographics
NPI:1356764195
Name:GREENHAGEN, CHRISTOPHER (PA-C)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:
Last Name:GREENHAGEN
Suffix:
Gender:M
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 1:1201 E HARTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2018
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5639
Practice Address - Street 1:716 S HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:NEWKIRK
Practice Address - State:OK
Practice Address - Zip Code:74647-7009
Practice Address - Country:US
Practice Address - Phone:580-362-2555
Practice Address - Fax:580-362-2948
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200530330AMedicaid
OK337245YRHZMedicare PIN