Provider Demographics
NPI:1003948597
Name:CHRISTIANSON, KELLE R (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLE
Middle Name:R
Last Name:CHRISTIANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 TWISTED OAK DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5311
Mailing Address - Country:US
Mailing Address - Phone:405-795-0004
Mailing Address - Fax:
Practice Address - Street 1:9917 SE 15TH ST
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5504
Practice Address - Country:US
Practice Address - Phone:405-622-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1551363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical