Provider Demographics
NPI:1366601015
Name:SHACKELFORD, CHARLOTTE L (PAC)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:L
Last Name:SHACKELFORD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 N 4TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-1806
Mailing Address - Country:US
Mailing Address - Phone:405-527-5400
Mailing Address - Fax:405-527-7332
Practice Address - Street 1:1401 N 4TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-1806
Practice Address - Country:US
Practice Address - Phone:405-527-5400
Practice Address - Fax:405-527-7332
Is Sole Proprietor?:No
Enumeration Date:2008-06-07
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK746363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00844211OtherRRMCARE THRU PFP
OK200229210AMedicaid
OKOKA100525Medicare PIN