Provider Demographics
NPI:1124794805
Name:WOFFORD, KATHRYN ROSE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ROSE
Last Name:WOFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9821 S 230TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-6852
Mailing Address - Country:US
Mailing Address - Phone:918-949-5160
Mailing Address - Fax:
Practice Address - Street 1:1910 S FALCON AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74019-2237
Practice Address - Country:US
Practice Address - Phone:183-419-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OK5166363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program