Provider Demographics
NPI:1285691287
Name:RODER, JEANNE ALICE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:ALICE
Last Name:RODER
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:525 SW 80TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139
Mailing Address - Country:US
Mailing Address - Phone:405-631-0481
Mailing Address - Fax:405-631-9025
Practice Address - Street 1:525 SW 80TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139
Practice Address - Country:US
Practice Address - Phone:405-631-0481
Practice Address - Fax:405-631-9025
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2019-08-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1115363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100191990AMedicaid
OK970018299OtherRAILROAD MEDICARE