Provider Demographics
NPI:1497742209
Name:SELLS, KRISTIN L (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:SELLS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 MANVEL AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-3856
Mailing Address - Country:US
Mailing Address - Phone:405-258-5252
Mailing Address - Fax:405-258-5552
Practice Address - Street 1:1116 S. MANVEL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-3856
Practice Address - Country:US
Practice Address - Phone:405-258-5252
Practice Address - Fax:405-258-5552
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100045300CMedicaid
OKS68640Medicare UPIN
OK100045300CMedicaid