Basic Information
| Provider Information | |||||||||
| NPI: | 1265921449 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PASSMAN | ||||||||
| FirstName: | SHAWNA | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E DOWNING ST | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744643324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184582406 | ||||||||
| FaxNumber: | 9184568886 | ||||||||
| Practice Location | |||||||||
| Address1: | 2405 W MAIN ST STE A | ||||||||
| Address2: | |||||||||
| City: | HENRYETTA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744373893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186501180 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2018 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 6720 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.