Healthcare Provider Details

I. General information

NPI: 1992461859
Provider Name (Legal Business Name): LISA GARDINER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 S BALTIMORE AVE
TULSA OK
74119-4807
US

IV. Provider business mailing address

3230 S WINSTON AVE APT 204
TULSA OK
74135-2079
US

V. Phone/Fax

Practice location:
  • Phone: 918-599-0532
  • Fax:
Mailing address:
  • Phone: 918-402-2258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: