Basic Information
| Provider Information | |||||||||
| NPI: | 1710289483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL PA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10701 POND MEADOW DR | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731519149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056010954 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 N MAY AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731126641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056010954 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2010 | ||||||||
| LastUpdateDate: | 12/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | DINWIDDIE | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4056010954 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | P.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1037 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.