Provider Demographics
NPI:1962557744
Name:ECKHARDT, PETER WERNER (PA-C)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:WERNER
Last Name:ECKHARDT
Suffix:
Gender:M
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:PO BOX 1118
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-1118
Mailing Address - Country:US
Mailing Address - Phone:918-756-9211
Mailing Address - Fax:918-756-9452
Practice Address - Street 1:900 E AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447
Practice Address - Country:US
Practice Address - Phone:918-756-9211
Practice Address - Fax:918-756-9452
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK000127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant