Basic Information
Provider Information | |||||||||
NPI: | 1366049280 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARTMAN | ||||||||
FirstName: | KELSEY | ||||||||
MiddleName: | KATHERINE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 527 W 3RD ST | ||||||||
Address2: |   | ||||||||
City: | KONAWA | ||||||||
State: | OK | ||||||||
PostalCode: | 748491415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5809253286 | ||||||||
FaxNumber: | 5809252362 | ||||||||
Practice Location | |||||||||
Address1: | 1221 ARLINGTON ST STE B | ||||||||
Address2: |   | ||||||||
City: | ADA | ||||||||
State: | OK | ||||||||
PostalCode: | 748204067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5804365111 | ||||||||
FaxNumber: | 5804361159 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2020 | ||||||||
LastUpdateDate: | 11/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X |   |   | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 4493 | 01 | OK | OK BOARD OF MEDICAL LICENSURE | OTHER |