MEDICARE: MS. LISA LARAE MCENTIRE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1629315106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA LARAE MCENTIRE

Provider Business Mailing Address
First Line	:	3120 CARTER RD
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-0267
Country	:	US
Telephone Number	:	580-221-0781
Fax Number	:

Provider Business Practice Location Address
First Line	:	3120 CARTER RD
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-0267
Country	:	US
Telephone Number	:	580-221-0781
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2013
Last Update Date	:	03/22/2026

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