Healthcare Provider Details

I. General information

NPI: 1104896760
Provider Name (Legal Business Name): LISA DANETTE WEST PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S TELEPHONE RD
MOORE OK
73160-5423
US

IV. Provider business mailing address

3555 NW 58TH ST SUITE 900
OKLAHOMA CITY OK
73112-4707
US

V. Phone/Fax

Practice location:
  • Phone: 405-793-9355
  • Fax: 405-793-1621
Mailing address:
  • Phone: 405-917-0418
  • Fax: 405-917-0419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1163
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: