Provider Demographics
NPI:1396812723
Name:ANDERSON, DONNA (PA)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 S SAINT LOUIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74120-5413
Mailing Address - Country:US
Mailing Address - Phone:918-592-0296
Mailing Address - Fax:918-592-0286
Practice Address - Street 1:1124 S SAINT LOUIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5413
Practice Address - Country:US
Practice Address - Phone:918-592-0296
Practice Address - Fax:918-592-0286
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK314363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100717240BMedicaid
OK100717240BMedicaid
R89717Medicare UPIN