Healthcare Provider Details

I. General information

NPI: 1558730242
Provider Name (Legal Business Name): CARISSA HINES- LAWSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 02/13/2024
Certification Date: 02/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12142 S YUKON AVE
GLENPOOL OK
74033-6621
US

IV. Provider business mailing address

12142 S YUKON AVE
GLENPOOL OK
74033-6621
US

V. Phone/Fax

Practice location:
  • Phone: 918-935-3636
  • Fax:
Mailing address:
  • Phone: 918-935-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2568
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2568
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: