MEDICARE: KELLY J WALWORTH PAC

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	1460	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710198569	OTHER	OK	GROUP NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376526756
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY J WALWORTH PAC

Provider Business Mailing Address
First Line	:	DEPT 96-0317
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73196-0317
Country	:	US
Telephone Number	:	405-521-1969
Fax Number	:	405-521-1979

Provider Business Practice Location Address
First Line	:	13174 N MACARTHUR BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-3017
Country	:	US
Telephone Number	:	405-721-5555
Fax Number	:	405-470-7093

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

Provider Enumeration Date	:	11/21/2005
Last Update Date	:	07/21/2022

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Directions to “ KELLY J WALWORTH PAC” Practice Location

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