Healthcare Provider Details

I. General information

NPI: 1598706491
Provider Name (Legal Business Name): KIMBERLEE R. MIXON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MONROE ST
ENID OK
73701-7211
US

IV. Provider business mailing address

1705 E 19TH ST STE 302
TULSA OK
74104-5410
US

V. Phone/Fax

Practice location:
  • Phone: 580-233-2300
  • Fax: 580-548-1489
Mailing address:
  • Phone: 580-748-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1288
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: