Provider Demographics
NPI:1912390238
Name:KUSHNERICK, KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KUSHNERICK
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 E 41ST ST STE 900
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5631
Mailing Address - Country:US
Mailing Address - Phone:918-934-8347
Mailing Address - Fax:918-743-8552
Practice Address - Street 1:5801 E 41ST ST STE 900
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5631
Practice Address - Country:US
Practice Address - Phone:918-934-8347
Practice Address - Fax:918-743-8552
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2536363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200601130AMedicaid