Provider Demographics
NPI:1669676961
Name:BRUNDIDGE, KASEY LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:LEE
Last Name:BRUNDIDGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1201 ARLINGTON ST
Mailing Address - Street 2:STE F
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4072
Mailing Address - Country:US
Mailing Address - Phone:580-279-1788
Mailing Address - Fax:580-279-1790
Practice Address - Street 1:1201 ARLINGTON ST
Practice Address - Street 2:STE F
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4072
Practice Address - Country:US
Practice Address - Phone:580-279-1788
Practice Address - Fax:580-279-1790
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2013-10-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK1618363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200161130AMedicaid
OK200471490AMedicaid
OK292736OtherMEDICARE GROUP
OK200471490AMedicaid