Provider Demographics
NPI:1598860520
Name:MOAK, KELLY DAWN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DAWN
Last Name:MOAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2100 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2736
Mailing Address - Country:US
Mailing Address - Phone:405-224-2100
Mailing Address - Fax:405-779-2244
Practice Address - Street 1:14321 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-8624
Practice Address - Country:US
Practice Address - Phone:405-342-0255
Practice Address - Fax:405-610-6960
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK2482363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical