Basic Information
| Provider Information | |||||||||
| NPI: | 1922099118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOXBERGER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | SUITE 919 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187286194 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 S UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187286194 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA712 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 970016049 | 01 | OK | RAILROAD MEDICARE | OTHER | 100039580A | 05 | OK | MEDICAID |