Provider Demographics
NPI:1063474344
Name:SMITH, LONNIE V (PA)
Entity Type:Individual
Prefix:
First Name:LONNIE
Middle Name:V
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:2115 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2109
Mailing Address - Country:US
Mailing Address - Phone:405-295-1166
Mailing Address - Fax:405-295-1334
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:ER DEPT.
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-752-3715
Practice Address - Fax:405-936-5058
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2015-03-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100117880BMedicaid
OK100117880AMedicaid
OK100117880BMedicaid
OK24H618620Medicare PIN
OKR85298Medicare UPIN
OK970021954Medicare PIN