Provider Demographics
NPI:1386701696
Name:WALDENVILLE, SUZZIE J (PA-C)
Entity type:Individual
Prefix:
First Name:SUZZIE
Middle Name:J
Last Name:WALDENVILLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NW H ST
Mailing Address - Street 2:P.O. BOX 728
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1625
Mailing Address - Country:US
Mailing Address - Phone:918-967-4682
Mailing Address - Fax:918-967-8694
Practice Address - Street 1:401 NW H ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1625
Practice Address - Country:US
Practice Address - Phone:918-967-4682
Practice Address - Fax:918-967-8694
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100716300BMedicaid