Provider Demographics
NPI:1396049086
Name:WILKINS, KELSEY D (PA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:D
Last Name:WILKINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:D
Other - Last Name:WALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2000 S WHEELING AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5649
Mailing Address - Country:US
Mailing Address - Phone:918-403-7070
Mailing Address - Fax:918-403-6327
Practice Address - Street 1:2000 S WHEELING AVE
Practice Address - Street 2:STE 100
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5649
Practice Address - Country:US
Practice Address - Phone:918-403-7070
Practice Address - Fax:918-403-6327
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200326430AMedicaid