Basic Information
| Provider Information | |||||||||
| NPI: | 1952384232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRESHAM | ||||||||
| FirstName: | TOM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4939 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741590939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187438943 | ||||||||
| FaxNumber: | 9187439058 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 S DARLINGTON AVE | ||||||||
| Address2: | STE 700 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187438943 | ||||||||
| FaxNumber: | 9187439058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 765 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100087830B | 05 | OK | MEDICAID |