Provider Demographics
NPI:1750002945
Name:ROBINSON, SHANTELL (PA)
Entity type:Individual
Prefix:
First Name:SHANTELL
Middle Name:
Last Name:ROBINSON
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 1:1415 NW 43RD ST STE 104
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-5027
Mailing Address - Country:US
Mailing Address - Phone:405-362-6399
Mailing Address - Fax:405-444-3025
Practice Address - Street 1:1415 NW 43RD ST STE 104
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-5027
Practice Address - Country:US
Practice Address - Phone:405-362-6399
Practice Address - Fax:580-215-5764
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKHFCFRJ2N171400000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1790418283Medicaid
OK1750002945Medicaid
OKF0610518Medicaid
OK1558675074Medicaid