=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467856088
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA LOUISE BAKER COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2014
-----------------------------------------------------
Last Update Date | 10/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8903 N 121ST EAST AVE
-----------------------------------------------------
City | OWASSO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74055-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-645-0375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8903 N 121ST EAST AVE
-----------------------------------------------------
City | OWASSO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74055-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-645-0375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A207
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------