Provider Demographics
NPI:1073025920
Name:SUMMARS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SUMMARS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 LYRIC ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-1546
Mailing Address - Country:US
Mailing Address - Phone:405-517-6877
Mailing Address - Fax:
Practice Address - Street 1:1201 N 8TH ST
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-9361
Practice Address - Country:US
Practice Address - Phone:405-872-3452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK736021050Medicaid