Provider Demographics
NPI:1104131721
Name:CENTRAL PA
Entity type:Organization
Organization Name:CENTRAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:W
Authorized Official - Last Name:DINWIDDIE
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:405-771-4151
Mailing Address - Street 1:10701 POND MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73151-9149
Mailing Address - Country:US
Mailing Address - Phone:405-771-4151
Mailing Address - Fax:
Practice Address - Street 1:10701 POND MEADOW DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73151-9149
Practice Address - Country:US
Practice Address - Phone:405-771-4151
Practice Address - Fax:405-771-4151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1037363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty