| Doctor Name: | QUINTON TY BOHANNON |
| NPI Number: | 1003154725 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | P.A.-C |
| License Number: | 2239 |
| Business Practice Address: | 108 W Ohio Ave Coalgate, OK - 745382827 |
| Business Phone Number: | 5809272334 |
| Business Fax Number: | |
| Mailing Address: | 108 W Ohio Ave, COALGATE |
| State: | OK |
| Postal Code: | 745382827 |
| Phone Number: | 5809272334 |
| Fax Number: | |
| NPI Enumeration Date: | 01/30/2013 |
| NPI Last Update Date: | 01/30/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 2239 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OK |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |