Healthcare Provider Details

I. General information

NPI: 1235108168
Provider Name (Legal Business Name): LAURA ANNE WALGREN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S BYRD ST
TISHOMINGO OK
73460-3265
US

IV. Provider business mailing address

1000 S BYRD ST
TISHOMINGO OK
73460-3265
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2327
  • Fax: 580-371-2127
Mailing address:
  • Phone: 580-371-2327
  • Fax: 580-371-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1658
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAD T 1735
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: