Healthcare Provider Details

I. General information

NPI: 1710528674
Provider Name (Legal Business Name): LISA RENEA PATE APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 FINLEY DR
ADA OK
74820-5392
US

IV. Provider business mailing address

730 FINLEY DR
ADA OK
74820-5392
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-6470
  • Fax:
Mailing address:
  • Phone: 580-421-6470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number104727
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: