Healthcare Provider Details

I. General information

NPI: 1649584855
Provider Name (Legal Business Name): LEA SARAH HUMPHREY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 E ROSS BYP
TAHLEQUAH OK
74464-4133
US

IV. Provider business mailing address

100 MERCY WAY STE 560
JOPLIN MO
64804-4524
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-1234
  • Fax: 918-453-9107
Mailing address:
  • Phone: 417-556-8555
  • Fax: 417-556-8553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number2010019023
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number6819
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: