Provider Demographics
NPI:1831791946
Name:SANDER, THOMAS CLAYTON (PA-C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:CLAYTON
Last Name:SANDER
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:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:OKEENE
Mailing Address - State:OK
Mailing Address - Zip Code:73763-0489
Mailing Address - Country:US
Mailing Address - Phone:580-822-4417
Mailing Address - Fax:
Practice Address - Street 1:207 E F ST
Practice Address - Street 2:
Practice Address - City:OKEENE
Practice Address - State:OK
Practice Address - Zip Code:73763-9441
Practice Address - Country:US
Practice Address - Phone:580-822-4337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant