Provider Demographics
NPI:1104997436
Name:BARENTINE, JEFFERY ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ALLEN
Last Name:BARENTINE
Suffix:
Gender:M
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 1:28622 E 141ST ST S
Mailing Address - Street 2:PO BOX 1030
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-7515
Mailing Address - Country:US
Mailing Address - Phone:918-486-7425
Mailing Address - Fax:918-279-6884
Practice Address - Street 1:28622 E 141ST ST S
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7515
Practice Address - Country:US
Practice Address - Phone:918-486-7425
Practice Address - Fax:918-279-6884
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1072574OtherNCCPA
OK1567OtherOKLAHOMA STATE LICENSE
OK1072574OtherNCCPA