Provider Demographics
NPI:1194759134
Name:PLAXICO, JANET LESLIE (PA)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:LESLIE
Last Name:PLAXICO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1008
Mailing Address - Country:US
Mailing Address - Phone:918-207-0991
Mailing Address - Fax:918-456-7570
Practice Address - Street 1:1201 E. ROSS BYPASS ROAD
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-207-0991
Practice Address - Fax:918-456-7570
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA772363AS0400X
OK772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100094770AMedicaid
OKOK400596Medicare PIN
S67032Medicare UPIN
OKS67032Medicare UPIN