Provider Demographics
NPI:1003071952
Name:MAXWELL, KEVIN J (PA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:J
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:1111 N LEE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2620
Mailing Address - Country:US
Mailing Address - Phone:405-600-6730
Mailing Address - Fax:405-600-6750
Practice Address - Street 1:1111 N LEE AVE STE 105
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2620
Practice Address - Country:US
Practice Address - Phone:405-600-6730
Practice Address - Fax:405-600-6750
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2013-06-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK638363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS02863Medicare UPIN