Basic Information
| Provider Information | |||||||||
| NPI: | 1720082266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODSON | ||||||||
| FirstName: | ALEXA | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRAITHWAITE | ||||||||
| OtherFirstName: | ALEXA | ||||||||
| OtherMiddleName: | GARNER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5300 N INDEPENDENCE AVE | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059173518 | ||||||||
| FaxNumber: | 4059514361 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 NW 56TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731124529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059173518 | ||||||||
| FaxNumber: | 4059514361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20116 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 245519606 | 01 | OK | MEDICARE NUMBER | OTHER |