Healthcare Provider Details

I. General information

NPI: 1205955432
Provider Name (Legal Business Name): PETER W KEUPEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6908 E RENO AVE
MIDWEST CITY OK
73110-2128
US

IV. Provider business mailing address

1305 BROAD ACRES DR
NORMAN OK
73072-3410
US

V. Phone/Fax

Practice location:
  • Phone: 405-737-6871
  • Fax:
Mailing address:
  • Phone: 405-255-6130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA748
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: