Provider Demographics
NPI:1275859621
Name:LORSEH, DIADRA (PA-C)
Entity Type:Individual
Prefix:
First Name:DIADRA
Middle Name:
Last Name:LORSEH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DIADRA
Other - Middle Name:
Other - Last Name:DYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2100 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2736
Mailing Address - Country:US
Mailing Address - Phone:405-224-2100
Mailing Address - Fax:405-779-2166
Practice Address - Street 1:2100 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2736
Practice Address - Country:US
Practice Address - Phone:405-224-2100
Practice Address - Fax:405-779-2166
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200411660AMedicaid
OK200411660AMedicaid