MEDICARE: MCKENZIE PITTMAN 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	363A00000X	Physician Assistant	2698	OK

General Provider Information

NPI Number	:	1982148524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZIE PITTMAN PA-C

Provider Business Mailing Address
First Line	:	PO BOX 108835
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73101-8835
Country	:	US
Telephone Number	:	405-608-6877
Fax Number	:	405-608-6899

Provider Business Practice Location Address
First Line	:	13220 N MACARTHUR BLVD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73142-3019
Country	:	US
Telephone Number	:	405-608-6877
Fax Number	:	405-521-1979

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

Provider Enumeration Date	:	12/16/2016
Last Update Date	:	11/30/2021

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