Provider Demographics
NPI:1669775714
Name:KADECHUK, LAURA LOUISE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LOUISE
Last Name:KADECHUK
Suffix:
Gender:F
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 1:2100 W IOWA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2736
Mailing Address - Country:US
Mailing Address - Phone:405-224-2100
Mailing Address - Fax:405-779-2365
Practice Address - Street 1:2100 W IOWA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2736
Practice Address - Country:US
Practice Address - Phone:405-224-2100
Practice Address - Fax:405-779-2365
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200317160AMedicaid
OKOKAAA0172Medicare PIN