Provider Demographics
NPI:1922036409
Name:DUREN, KELLY L (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:DUREN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 SW 44TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73179-4309
Mailing Address - Country:US
Mailing Address - Phone:405-357-3500
Mailing Address - Fax:405-357-3519
Practice Address - Street 1:7301 SW 44TH ST STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73179-4309
Practice Address - Country:US
Practice Address - Phone:405-357-3500
Practice Address - Fax:405-357-3519
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA008081Medicare ID - Type Unspecified
S57900Medicare UPIN