Provider Demographics
NPI:1316905110
Name:ODOM, DEBRA SUE (PA)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:ODOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:SUE
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1717A S UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104
Mailing Address - Country:US
Mailing Address - Phone:918-748-1300
Mailing Address - Fax:918-748-1303
Practice Address - Street 1:1717A S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104
Practice Address - Country:US
Practice Address - Phone:918-748-1300
Practice Address - Fax:918-748-1303
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1340363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200023180AMedicaid
OKOK401882Medicare PIN
OKQ10763Medicare UPIN