Healthcare Provider Details

I. General information

NPI: 1831346949
Provider Name (Legal Business Name): CAROL LE HOMER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL MAU LE PA-C

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 W MEMORIAL RD
OKLAHOMA CITY OK
73120-8304
US

IV. Provider business mailing address

4300 W MEMORIAL RD
OKLAHOMA CITY OK
73120-8304
US

V. Phone/Fax

Practice location:
  • Phone: 405-752-3715
  • Fax: 405-936-5058
Mailing address:
  • Phone: 405-752-3715
  • Fax: 405-936-5058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05959
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2163
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: