Provider Demographics
NPI:1235108168
Name:WALGREN, LAURA ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:WALGREN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 S BYRD ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3265
Mailing Address - Country:US
Mailing Address - Phone:580-371-2327
Mailing Address - Fax:580-371-2889
Practice Address - Street 1:1000 S BYRD ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3265
Practice Address - Country:US
Practice Address - Phone:580-371-2327
Practice Address - Fax:580-371-2127
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPAD T 1735363AM0700X
OK1658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical