Healthcare Provider Details

I. General information

NPI: 1710976071
Provider Name (Legal Business Name): KATHERINE J PAYNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 06/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 NE 36TH ST
OKLAHOMA CITY OK
73105-7203
US

IV. Provider business mailing address

701 NE 36TH ST
OKLAHOMA CITY OK
73105-7203
US

V. Phone/Fax

Practice location:
  • Phone: 405-631-0611
  • Fax: 405-631-0811
Mailing address:
  • Phone: 405-631-0611
  • Fax: 405-631-0811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1189
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1189
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: