Provider Demographics
NPI:1801075262
Name:HARDESTY, KAYLA DIANE (PA-C, PT)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:DIANE
Last Name:HARDESTY
Suffix:
Gender:F
Credentials:PA-C, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 720006
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4006
Mailing Address - Country:US
Mailing Address - Phone:405-707-0900
Mailing Address - Fax:
Practice Address - Street 1:511 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-6962
Practice Address - Country:US
Practice Address - Phone:405-707-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1686363A00000X, 363A00000X
OK2970225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200215910AMedicaid
OKOK405018Medicare PIN