Provider Demographics
NPI:1548327653
Name:THENMADATHIL, MERRY MATHEW (PA)
Entity type:Individual
Prefix:
First Name:MERRY
Middle Name:MATHEW
Last Name:THENMADATHIL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MERRY
Other - Middle Name:
Other - Last Name:MATHEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9900 BROADWAY EXT STE 200
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-6323
Mailing Address - Country:US
Mailing Address - Phone:405-608-8833
Mailing Address - Fax:405-608-8188
Practice Address - Street 1:9900 BROADWAY EXT STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-6323
Practice Address - Country:US
Practice Address - Phone:405-608-8833
Practice Address - Fax:405-608-8188
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011540363AM0700X
OK1857363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY789713491Medicare PIN