Provider Demographics
NPI:1407584717
Name:GRIGSBY, DAXTON THANE (PA)
Entity type:Individual
Prefix:
First Name:DAXTON
Middle Name:THANE
Last Name:GRIGSBY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2536
Mailing Address - Country:US
Mailing Address - Phone:918-660-3842
Mailing Address - Fax:
Practice Address - Street 1:19600 E ROSS ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-0545
Practice Address - Country:US
Practice Address - Phone:539-234-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-13
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant