Basic Information
| Provider Information | |||||||||
| NPI: | 1609016708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCASKILL | ||||||||
| FirstName: | KIZZY | ||||||||
| MiddleName: | LANAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEWETT | ||||||||
| OtherFirstName: | KIZZY | ||||||||
| OtherMiddleName: | LANAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053075720 | ||||||||
| FaxNumber: | 4053075721 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 W TECUMSEH RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730721811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053075720 | ||||||||
| FaxNumber: | 4053075721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2009 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1806 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200259700A | 05 | OK | MEDICAID |