Provider Demographics
NPI:1912721648
Name:MCCOY, GAGE BLACKSTONE
Entity type:Individual
Prefix:
First Name:GAGE
Middle Name:BLACKSTONE
Last Name:MCCOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 N KELLEY AVE APT 611
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1479
Mailing Address - Country:US
Mailing Address - Phone:501-580-2436
Mailing Address - Fax:
Practice Address - Street 1:630 N KELLEY AVE APT 611
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1479
Practice Address - Country:US
Practice Address - Phone:501-580-2436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program