Healthcare Provider Details

I. General information

NPI: 1235293804
Provider Name (Legal Business Name): LEE RICHERSON MACKIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13100 N WESTERN AVE STE 303
OKLAHOMA CITY OK
73114-1432
US

IV. Provider business mailing address

13100 N WESTERN AVE STE 303
OKLAHOMA CITY OK
73114-1432
US

V. Phone/Fax

Practice location:
  • Phone: 800-781-1220
  • Fax: 888-678-8616
Mailing address:
  • Phone: 800-781-1220
  • Fax: 888-678-8616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-508
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5062
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: