Provider Demographics
NPI:1528684388
Name:ADMIRE, KATELYN (PAC)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:ADMIRE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17142 S 4480 RD
Mailing Address - Street 2:
Mailing Address - City:BLUEJACKET
Mailing Address - State:OK
Mailing Address - Zip Code:74333-4582
Mailing Address - Country:US
Mailing Address - Phone:757-621-0249
Mailing Address - Fax:
Practice Address - Street 1:1001 E 18TH ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2907
Practice Address - Country:US
Practice Address - Phone:918-786-2243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OK4398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant