Provider Demographics
NPI:1710611884
Name:KABASAWA, DEREK (PA-C)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:KABASAWA
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 1:13821 TECHNOLOGY DR STE B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1046
Mailing Address - Country:US
Mailing Address - Phone:405-451-3454
Mailing Address - Fax:
Practice Address - Street 1:13821 TECHNOLOGY DR STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1046
Practice Address - Country:US
Practice Address - Phone:405-451-3454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant