Provider Demographics
NPI:1588106488
Name:CUMPSTON, CARMEN SANDER (PA)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:SANDER
Last Name:CUMPSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:SANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3201 N VAN BUREN ST STE 400
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-1800
Mailing Address - Country:US
Mailing Address - Phone:580-297-6697
Mailing Address - Fax:
Practice Address - Street 1:3201 N VAN BUREN ST STE 400
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-1800
Practice Address - Country:US
Practice Address - Phone:580-237-1877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant