Basic Information
| Provider Information | |||||||||
| NPI: | 1447258405 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIVENS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | EDITH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2080 W STATE HIGHWAY 9 | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730729795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053607100 | ||||||||
| FaxNumber: | 4053649112 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 W TECUMSEH RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730721810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053607100 | ||||||||
| FaxNumber: | 4053649112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 08/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA806 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100125270A | 05 | OK | MEDICAID |