Provider Demographics
NPI:1215261367
Name:MURRAY, NATHAN DANIEL (PA)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:DANIEL
Last Name:MURRAY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:NATHAN
Other - Middle Name:DANIEL
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1011 14TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1828
Mailing Address - Country:US
Mailing Address - Phone:580-220-6658
Mailing Address - Fax:580-220-6673
Practice Address - Street 1:1011 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1828
Practice Address - Country:US
Practice Address - Phone:580-220-6658
Practice Address - Fax:580-220-6673
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16223363A00000X
OK1798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699960AMedicaid