Provider Demographics
NPI:1982148524
Name:PITTMAN, MCKENZIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:PITTMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MCKENZIE
Other - Middle Name:
Other - Last Name:WALTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 108835
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8835
Mailing Address - Country:US
Mailing Address - Phone:405-608-6877
Mailing Address - Fax:405-608-6899
Practice Address - Street 1:13220 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-3019
Practice Address - Country:US
Practice Address - Phone:405-608-6877
Practice Address - Fax:405-521-1979
Is Sole Proprietor?:No
Enumeration Date:2016-12-16
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant