Provider Demographics
NPI:1932141728
Name:PLUMMER, KEITH GERRELL (PA-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:GERRELL
Last Name:PLUMMER
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 1:610 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-371-2343
Mailing Address - Fax:580-371-2451
Practice Address - Street 1:610 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3245
Practice Address - Country:US
Practice Address - Phone:580-371-2343
Practice Address - Fax:580-371-2451
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK794363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100058030BMedicaid
OK100058030BMedicaid