Basic Information
| Provider Information | |||||||||
| NPI: | 1649937731 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARCIA | ||||||||
| FirstName: | KENNEDY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11953 S 88TH EAST AVE | ||||||||
| Address2: | |||||||||
| City: | BIXBY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740081825 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 471688 HIGHWAY 51 | ||||||||
| Address2: | |||||||||
| City: | STILWELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749604490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186968800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2021 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4692 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.