Provider Demographics
NPI:1063711190
Name:WAGENER, BETHANY GALE (PA-C)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:GALE
Last Name:WAGENER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9014 W ROGERS BLVD
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-5528
Mailing Address - Country:US
Mailing Address - Phone:405-408-3547
Mailing Address - Fax:
Practice Address - Street 1:2901 N CLASSEN BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-5493
Practice Address - Country:US
Practice Address - Phone:918-594-1300
Practice Address - Fax:918-594-1312
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAPA2006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant