Healthcare Provider Details

I. General information

NPI: 1063138170
Provider Name (Legal Business Name): LARAMIE KUYKENDALL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S DOBSON RD
MESA AZ
85202-4707
US

IV. Provider business mailing address

674 BELMAR BLVD
NORMAN OK
73071-8006
US

V. Phone/Fax

Practice location:
  • Phone: 480-412-3000
  • Fax:
Mailing address:
  • Phone: 405-740-8459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10566
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4865
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-02718
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: