Healthcare Provider Details

I. General information

NPI: 1992249486
Provider Name (Legal Business Name): KENNETH GAROLD FOSTER JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5252 N MERIDIAN AVE SUITE 101
OKLAHOMA CITY OK
73112-2178
US

IV. Provider business mailing address

5252 N MERIDIAN AVE SUITE 101
OKLAHOMA CITY OK
73112-2178
US

V. Phone/Fax

Practice location:
  • Phone: 405-789-0458
  • Fax: 405-787-0184
Mailing address:
  • Phone: 405-789-0458
  • Fax: 405-787-0184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 2703
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: