Provider Demographics
NPI:1538946512
Name:PATTON, KENNETH WAYNE SR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WAYNE
Last Name:PATTON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7323 E NASHVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2980
Mailing Address - Country:US
Mailing Address - Phone:918-853-5153
Mailing Address - Fax:
Practice Address - Street 1:7323 E NASHVILLE ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2980
Practice Address - Country:US
Practice Address - Phone:918-853-5153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2021-889175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist