Basic Information
Provider Information | |||||||||
NPI: | 1700877321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WELCH | ||||||||
FirstName: | CATHY | ||||||||
MiddleName: | LOUISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14449 N 525 RD | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744640443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184311599 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1203 E ROSS BYP | ||||||||
Address2: | SUITE A | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744644133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184531234 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2005 | ||||||||
LastUpdateDate: | 05/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA769 | OK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 100313470B | 05 | OK |   | MEDICAID | 400522239 | 01 | OK | MEDICARE GROUP PTAN | OTHER | 200000030A | 05 | OK |   | MEDICAID |