Provider Demographics
NPI:1144934589
Name:PECK, JOHNATHAN W (DMS, PA-C)
Entity type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:W
Last Name:PECK
Suffix:
Gender:M
Credentials:DMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 E 51ST ST STE 3
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74134-6712
Mailing Address - Country:US
Mailing Address - Phone:918-994-3476
Mailing Address - Fax:
Practice Address - Street 1:12902 E 51ST ST STE 3
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-6712
Practice Address - Country:US
Practice Address - Phone:918-994-3476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4971363A00000X
FLPA9117435363A00000X
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant