Provider Demographics
NPI:1205955432
Name:KEUPEN, PETER W (PA-C)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:W
Last Name:KEUPEN
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 1:1305 BROAD ACRES DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-3410
Mailing Address - Country:US
Mailing Address - Phone:405-255-6130
Mailing Address - Fax:
Practice Address - Street 1:6908 E RENO AVE
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-2128
Practice Address - Country:US
Practice Address - Phone:405-737-6871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA748363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical