Provider Demographics
NPI:1487924098
Name:PECK, KRISTIN M (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:PECK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8921 S MINGO RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:918-252-8060
Mailing Address - Fax:918-254-9583
Practice Address - Street 1:8921 S MINGO RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-252-8060
Practice Address - Fax:918-254-9583
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363AM0700X
OK2112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical