Provider Demographics
NPI:1093783458
Name:WEBB, KIZZY JOY (PAC)
Entity Type:Individual
Prefix:
First Name:KIZZY
Middle Name:JOY
Last Name:WEBB
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3347
Mailing Address - Country:US
Mailing Address - Phone:918-488-6001
Mailing Address - Fax:
Practice Address - Street 1:10507 E 91ST ST
Practice Address - Street 2:SUITE 550
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5589
Practice Address - Country:US
Practice Address - Phone:918-307-3060
Practice Address - Fax:918-307-3061
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP86172Medicare UPIN