Provider Demographics
NPI:1518145135
Name:WEST, KELLY G (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:WEST
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:G
Other - Last Name:POUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:6600 S YALE AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3361
Mailing Address - Country:US
Mailing Address - Phone:918-488-6687
Mailing Address - Fax:918-488-6098
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-1805
Practice Address - Fax:918-494-4573
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1716363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid
OKPENDINGOtherRAILROAD MEDICARE
OKPENDINGOtherRAILROAD MEDICARE
OKPENDINGMedicare UPIN