Provider Demographics
NPI:1609016708
Name:MCCASKILL, KIZZY LANAE (PA)
Entity Type:Individual
Prefix:
First Name:KIZZY
Middle Name:LANAE
Last Name:MCCASKILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KIZZY
Other - Middle Name:LANAE
Other - Last Name:HEWETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-307-5720
Mailing Address - Fax:405-307-5721
Practice Address - Street 1:3400 W TECUMSEH RD
Practice Address - Street 2:SUITE 203
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1811
Practice Address - Country:US
Practice Address - Phone:405-307-5720
Practice Address - Fax:405-307-5721
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200259700AMedicaid
OK200259700AMedicaid