Healthcare Provider Details

I. General information

NPI: 1063480333
Provider Name (Legal Business Name): LAURIE J HAST MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 BLUE WISTER CV
EDMOND OK
73013-1367
US

IV. Provider business mailing address

1208 BLUE WISTER CV
EDMOND OK
73013-1367
US

V. Phone/Fax

Practice location:
  • Phone: 405-255-4519
  • Fax:
Mailing address:
  • Phone: 405-255-4519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number19623
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: