Provider Demographics
NPI:1164492211
Name:PAXSON, LAURIE SUE (PA)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:SUE
Last Name:PAXSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2847
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:580-421-6283
Practice Address - Street 1:1001 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2847
Practice Address - Country:US
Practice Address - Phone:580-421-4570
Practice Address - Fax:580-421-6283
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP8735Medicare UPIN