Provider Demographics
NPI:1972876191
Name:GAYDOS, KALA MARIE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:KALA
Middle Name:MARIE
Last Name:GAYDOS
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10512 N 110TH EAST AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-6638
Mailing Address - Country:US
Mailing Address - Phone:918-376-8830
Mailing Address - Fax:918-376-8839
Practice Address - Street 1:3336 E 32ND ST STE 220
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-398-0800
Practice Address - Fax:918-398-0800
Is Sole Proprietor?:No
Enumeration Date:2012-02-18
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK96559363LP2300X, 363L00000X
TX820817363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200772750AMedicaid