Provider Demographics
NPI:1568766863
Name:GEORGE, SEAN KENNY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:KENNY
Last Name:GEORGE
Suffix:
Gender:M
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 1:4334 NW EXPRESSWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1578
Mailing Address - Country:US
Mailing Address - Phone:405-921-8270
Mailing Address - Fax:
Practice Address - Street 1:4334 NW EXPRESSWAY
Practice Address - Street 2:SUITE 201
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1578
Practice Address - Country:US
Practice Address - Phone:405-921-8270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1963363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100221930AMedicaid
OK585488709PMedicare PIN