Healthcare Provider Details

I. General information

NPI: 1932141728
Provider Name (Legal Business Name): KEITH GERRELL PLUMMER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 E 24TH ST
TISHOMINGO OK
73460-3245
US

IV. Provider business mailing address

610 E 24TH ST
TISHOMINGO OK
73460-3245
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2343
  • Fax: 580-371-2451
Mailing address:
  • Phone: 580-371-2343
  • Fax: 580-371-2451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number794
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: