Provider Demographics
NPI:1699865162
Name:JOHNSON, RUTH (PA)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CIMARRON DR
Mailing Address - Street 2:BOX 323
Mailing Address - City:MANNFORD
Mailing Address - State:OK
Mailing Address - Zip Code:74044-9504
Mailing Address - Country:US
Mailing Address - Phone:918-865-5000
Mailing Address - Fax:918-865-5050
Practice Address - Street 1:500 CIMARRON DR
Practice Address - Street 2:BOX 323
Practice Address - City:MANNFORD
Practice Address - State:OK
Practice Address - Zip Code:74044-9504
Practice Address - Country:US
Practice Address - Phone:918-865-5000
Practice Address - Fax:918-865-5050
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKPA-1777363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56884P156Medicare PIN
P20186Medicare UPIN