Basic Information
| Provider Information | |||||||||
| NPI: | 1043292493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAUBION | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053076668 | ||||||||
| FaxNumber: | 4057016170 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 SE 4TH ST | ||||||||
| Address2: | |||||||||
| City: | MOORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731606709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057944664 | ||||||||
| FaxNumber: | 4057942853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 04/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3260 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 3260 | OK | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100125330B | 05 | OK | MEDICAID |