Provider Demographics
NPI:1619930005
Name:STEIN, KENNETH MICHAEL (PAC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:STEIN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 NW 9TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1070
Mailing Address - Country:US
Mailing Address - Phone:405-272-6027
Mailing Address - Fax:405-272-8315
Practice Address - Street 1:535 NW 9TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1070
Practice Address - Country:US
Practice Address - Phone:405-272-6027
Practice Address - Fax:405-272-8315
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
432908895002OtherCUSTOM GROUP SERVICES
432908895002OtherBLUE CROSS BLUE SHIELD
731461178005OtherTRICARE
OK100003580AMedicaid
S83200Medicare UPIN
432908895002OtherCUSTOM GROUP SERVICES