Provider Demographics
NPI:1912744004
Name:CULLISON, KAEGAN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KAEGAN
Middle Name:MARIE
Last Name:CULLISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAEGAN
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 QUAIL SPRINGS PKWY FL 5
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-2640
Mailing Address - Country:US
Mailing Address - Phone:405-949-3349
Mailing Address - Fax:405-945-5467
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4418
Practice Address - Country:US
Practice Address - Phone:405-949-3349
Practice Address - Fax:405-945-5467
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant