Basic Information
| Provider Information | |||||||||
| NPI: | 1487626826 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RISLEY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 S WALKER AVE | ||||||||
| Address2: | BLDG A | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731399404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057523162 | ||||||||
| FaxNumber: | 4059365211 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MEMORIAL RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056322323 | ||||||||
| FaxNumber: | 4056319315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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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 | 363AS0400X | 1111 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 200067440A | 05 | OK | MEDICAID | 970025354 | 01 | OK | RAILROAD MEDICARE | OTHER |