Provider Demographics
NPI:1881695948
Name:MCHENRY, JASON R (PA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:MCHENRY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N PARK DR
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-2146
Mailing Address - Country:US
Mailing Address - Phone:580-584-7210
Mailing Address - Fax:580-584-7213
Practice Address - Street 1:800 N PARK DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-2146
Practice Address - Country:US
Practice Address - Phone:580-584-7210
Practice Address - Fax:580-584-7213
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200015540AMedicaid
OK200015540AMedicaid