Provider Demographics
NPI:1740515295
Name:MARTIN-DEANGELIS, ADRIENNE ALLISON (PA)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:ALLISON
Last Name:MARTIN-DEANGELIS
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 1:3435 NW 56TH ST
Mailing Address - Street 2:STE 404
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4414
Mailing Address - Country:US
Mailing Address - Phone:405-751-1530
Mailing Address - Fax:
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:STE 618
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-751-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant