Provider Demographics
NPI:1730215708
Name:KERSEY, CHANDA T (PA)
Entity type:Individual
Prefix:
First Name:CHANDA
Middle Name:T
Last Name:KERSEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 848371
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8371
Mailing Address - Country:US
Mailing Address - Phone:904-446-3451
Mailing Address - Fax:904-446-3013
Practice Address - Street 1:5200 E I 240 SERVICE RD
Practice Address - Street 2:OKLAHOMA HEART HOSPITAL SOUTH WOUND CARE CENTER
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-2607
Practice Address - Country:US
Practice Address - Phone:405-628-6405
Practice Address - Fax:405-753-1849
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQ65005Medicare UPIN