Healthcare Provider Details

I. General information

NPI: 1710805973
Provider Name (Legal Business Name): KALOB MICHAEL BLACKWELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4409 N KICKAPOO AVE
SHAWNEE OK
74804-1206
US

IV. Provider business mailing address

4409 N KICKAPOO AVE
SHAWNEE OK
74804-1206
US

V. Phone/Fax

Practice location:
  • Phone: 405-242-4100
  • Fax:
Mailing address:
  • Phone: 405-242-4100
  • Fax: 405-775-9356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6206
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: