Healthcare Provider Details

I. General information

NPI: 1366166225
Provider Name (Legal Business Name): DONOVAN KYLE HEFFLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 13TH ST
OKLAHOMA CITY OK
73104-5004
US

IV. Provider business mailing address

2620 N REDMOND AVE
OKLAHOMA CITY OK
73127-1432
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-4700
  • Fax:
Mailing address:
  • Phone: 405-600-5876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberAP65427076
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: