Healthcare Provider Details

I. General information

NPI: 1710903604
Provider Name (Legal Business Name): LAURIE LEIGH ISENBERG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7333 E 121ST ST S
BIXBY OK
74008
US

IV. Provider business mailing address

7333 E 121ST ST S
BIXBY OK
74008-2654
US

V. Phone/Fax

Practice location:
  • Phone: 918-403-7140
  • Fax: 918-856-5392
Mailing address:
  • Phone: 918-403-7140
  • Fax: 918-856-5392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1342
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: