Healthcare Provider Details

I. General information

NPI: 1336779206
Provider Name (Legal Business Name): JOHN NELSON LAZENBY III MHS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 E CLARK BASS BLVD STE 302
MCALESTER OK
74501-4269
US

IV. Provider business mailing address

6708 TREVI CT
OKLAHOMA CITY OK
73116-2604
US

V. Phone/Fax

Practice location:
  • Phone: 918-426-4306
  • Fax:
Mailing address:
  • Phone: 580-695-2958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3133
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: