Provider Demographics
NPI:1396093647
Name:CALDWELL, AUTUM MICHOLE (PA - C)
Entity type:Individual
Prefix:
First Name:AUTUM
Middle Name:MICHOLE
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:AUTUM
Other - Middle Name:MICHOLE
Other - Last Name:LACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA - C
Mailing Address - Street 1:6565 S YALE AVE
Mailing Address - Street 2:SUITE 503
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8327
Mailing Address - Country:US
Mailing Address - Phone:918-494-8333
Mailing Address - Fax:918-494-8334
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8327
Practice Address - Country:US
Practice Address - Phone:918-494-8333
Practice Address - Fax:918-494-8334
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant