Provider Demographics
NPI:1487323036
Name:DAUGHERTY, MARY KAY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KAY
Last Name:DAUGHERTY
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 1:1809 E 13TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4431
Mailing Address - Country:US
Mailing Address - Phone:918-579-2300
Mailing Address - Fax:
Practice Address - Street 1:1809 E 13TH ST STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4431
Practice Address - Country:US
Practice Address - Phone:918-579-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4776363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical