MEDICARE: KOHL JEFFRY KIMMEL

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	363A00000X	Physician Assistant	5634	OK

General Provider Information

NPI Number	:	1336966647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KOHL JEFFRY KIMMEL

Provider Business Mailing Address
First Line	:	1608 CASTLE ROCK RD
Second Line	:
City	:	YUKON
State	:	OK
Zip	:	73099-4429
Country	:	US
Telephone Number	:	405-301-9988
Fax Number	:

Provider Business Practice Location Address
First Line	:	1608 CASTLE ROCK RD
Second Line	:
City	:	YUKON
State	:	OK
Zip	:	73099-4429
Country	:	US
Telephone Number	:	405-301-9988
Fax Number	:

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

Provider Enumeration Date	:	09/26/2024
Last Update Date	:	03/10/2026

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