Provider Demographics
NPI:1275707408
Name:RASMUSSEN, KEITH ALEX (PA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALEX
Last Name:RASMUSSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 SW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-5928
Mailing Address - Country:US
Mailing Address - Phone:405-295-2200
Mailing Address - Fax:405-295-2178
Practice Address - Street 1:605 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-5928
Practice Address - Country:US
Practice Address - Phone:405-295-2200
Practice Address - Fax:405-295-2178
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1725363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734110BMedicaid