Provider Demographics
NPI:1881794295
Name:ATWOOD, PEGGY SUE (PA-C)
Entity type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:SUE
Last Name:ATWOOD
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 1:200 N EASTON
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:OK
Mailing Address - Zip Code:74825-9713
Mailing Address - Country:US
Mailing Address - Phone:580-857-1300
Mailing Address - Fax:580-857-1302
Practice Address - Street 1:200 N EASTON
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:OK
Practice Address - Zip Code:74825-9713
Practice Address - Country:US
Practice Address - Phone:580-857-1300
Practice Address - Fax:580-857-1302
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100631940CMedicaid
OKOKA100161OtherMCR INDIVIDUAL PTAN
OK100631940CMedicaid