Healthcare Provider Details

I. General information

NPI: 1396095360
Provider Name (Legal Business Name): KATHY SONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356110 E 930 RD
STROUD OK
74079-5184
US

IV. Provider business mailing address

2868 ACTON RD
VESTAVIA AL
35243-2502
US

V. Phone/Fax

Practice location:
  • Phone: 918-968-9531
  • Fax:
Mailing address:
  • Phone: 205-379-6075
  • Fax: 866-702-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1287
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2160
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: