Provider Demographics
NPI:1700877321
Name:WELCH, CATHY LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:LOUISE
Last Name:WELCH
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 1:14449 N 525 RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-0443
Mailing Address - Country:US
Mailing Address - Phone:918-431-1599
Mailing Address - Fax:
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4133
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100313470BMedicaid
OK400522239OtherMEDICARE GROUP PTAN
OK200000030AMedicaid
OK249610101Medicare PIN
OK100313470BMedicaid