Basic Information
| Provider Information | |||||||||
| NPI: | 1548200751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETRAY | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N HARVARD AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741154957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | 9188326055 | ||||||||
| Practice Location | |||||||||
| Address1: | 13600 E 86TH ST N | ||||||||
| Address2: | 100 | ||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740558731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182729313 | ||||||||
| FaxNumber: | 9182933117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 02/09/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 16104 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1000074870A | 05 | OK | MEDICAID |