Individual
MR. WILLIE J STREET
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
P.A.-C
Contact information
Practice address
600 E GRAND AVE, TONKAWA, OK 74653-3545
(580) 628-4800
Mailing address
PO BOX 532, TONKAWA, OK 74653-0532
(580) 628-4800
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
631
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100101960G
—
OK
Enumeration date
11/30/2006
Last updated
03/07/2012
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