Provider Demographics
NPI:1952384232
Name:GRESHAM, TOM J (PA)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:J
Last Name:GRESHAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4939
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74159-0939
Mailing Address - Country:US
Mailing Address - Phone:918-743-8943
Mailing Address - Fax:918-743-9058
Practice Address - Street 1:4111 S DARLINGTON AVE
Practice Address - Street 2:STE 700
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6348
Practice Address - Country:US
Practice Address - Phone:918-743-8943
Practice Address - Fax:918-743-9058
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2013-08-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100087830BMedicaid
OK243516500Medicare ID - Type Unspecified
OK100087830BMedicaid