Basic Information
Provider Information | |||||||||
NPI: | 1730188863 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCKEE | ||||||||
FirstName: | KRISTI | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WADLEY | ||||||||
OtherFirstName: | KRISTI | ||||||||
OtherMiddleName: | DIANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5038 | ||||||||
Address2: |   | ||||||||
City: | ENID | ||||||||
State: | OK | ||||||||
PostalCode: | 737025038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5805481367 | ||||||||
FaxNumber: | 5805481537 | ||||||||
Practice Location | |||||||||
Address1: | 1805 W GARRIOTT RD | ||||||||
Address2: |   | ||||||||
City: | ENID | ||||||||
State: | OK | ||||||||
PostalCode: | 737035526 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5802339012 | ||||||||
FaxNumber: | 5802494269 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2005 | ||||||||
LastUpdateDate: | 10/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA778 | OK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 200008710A | 05 | OK |   | MEDICAID |