Basic Information
| Provider Information | |||||||||
| NPI: | 1720015241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUBE | ||||||||
| FirstName: | BERNADETTE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9600 BROADWAY EXT | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731147408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052309000 | ||||||||
| FaxNumber: | 4052309157 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 W RENO AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731276346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052309250 | ||||||||
| FaxNumber: | 4059430742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 08/09/2019 | ||||||||
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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 | 648 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.