1194295410 NPI number — JILLIAN POLLARD PA-C

Table of content: JILLIAN POLLARD PA-C (NPI 1194295410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194295410 NPI number — JILLIAN POLLARD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLLARD
Provider First Name:
JILLIAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REAMES
Provider Other First Name:
JILLIAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194295410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7800 NW 85TH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73132-3385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-972-7239
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5224 E I 240 SERVICE RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-608-3800
Provider Business Practice Location Address Fax Number:
405-628-6495
Provider Enumeration Date:
11/29/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  2930 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2930 . This is a "OKLAHOMA PA LICENSE NUMBER" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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