Provider Demographics
NPI:1952404238
Name:MASSENGILL, JAMIE SHANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:SHANE
Last Name:MASSENGILL
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 1:7555 WINTERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73025-1861
Mailing Address - Country:US
Mailing Address - Phone:405-990-5967
Mailing Address - Fax:
Practice Address - Street 1:7555 WINTERWOOD DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73025-1861
Practice Address - Country:US
Practice Address - Phone:405-990-5967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1320363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ07184Medicare UPIN