Provider Demographics
NPI:1205822392
Name:TANYA S. MACLAREN, DOPC
Entity Type:Organization
Organization Name:TANYA S. MACLAREN, DOPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-272-0485
Mailing Address - Street 1:PO BOX 108810
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8810
Mailing Address - Country:US
Mailing Address - Phone:580-272-0485
Mailing Address - Fax:580-332-5750
Practice Address - Street 1:3048 SW 89TH ST
Practice Address - Street 2:STE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6359
Practice Address - Country:US
Practice Address - Phone:580-272-0485
Practice Address - Fax:580-332-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3587207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100189620AMedicaid
OK100189620AMedicaid
OKOKB5572Medicare PIN