Provider Demographics
NPI:1992249486
Name:FOSTER, KENNETH GAROLD JR (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GAROLD
Last Name:FOSTER
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5252 N MERIDIAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2178
Mailing Address - Country:US
Mailing Address - Phone:405-789-0458
Mailing Address - Fax:405-787-0184
Practice Address - Street 1:5252 N MERIDIAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2178
Practice Address - Country:US
Practice Address - Phone:405-789-0458
Practice Address - Fax:405-787-0184
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA 2703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant