Healthcare Provider Details

I. General information

NPI: 1477922599
Provider Name (Legal Business Name): CARRIE IRENE CROSS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE IRENE CLARK PA

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W 151ST ST S STE 202
GLENPOOL OK
74033-4530
US

IV. Provider business mailing address

6600 S YALE AVE STE 1200
TULSA OK
74136-3333
US

V. Phone/Fax

Practice location:
  • Phone: 918-321-7400
  • Fax: 918-321-7415
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2622
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: