MEDICARE: MR. PETER W KEUPEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA748	OK

General Provider Information

NPI Number	:	1205955432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER W KEUPEN PA-C

Provider Business Mailing Address
First Line	:	1305 BROAD ACRES DR
Second Line	:
City	:	NORMAN
State	:	OK
Zip	:	73072-3410
Country	:	US
Telephone Number	:	405-255-6130
Fax Number	:

Provider Business Practice Location Address
First Line	:	6908 E RENO AVE
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-2128
Country	:	US
Telephone Number	:	405-737-6871
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	09/12/2013

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