Provider Demographics
NPI:1447436316
Name:ELROD, KIMBERLY ANNE (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:ELROD
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:BOLING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1992
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-1992
Mailing Address - Country:US
Mailing Address - Phone:918-426-2442
Mailing Address - Fax:918-426-0888
Practice Address - Street 1:3101 ELK DR
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-7606
Practice Address - Country:US
Practice Address - Phone:918-426-2442
Practice Address - Fax:918-421-6963
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA1694363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200133430AMedicaid