Provider Demographics
NPI:1376848689
Name:SHAO, LAURA BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:SHAO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:BETH
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-793-9355
Mailing Address - Fax:405-912-3191
Practice Address - Street 1:3400 W TECUMSEH RD
Practice Address - Street 2:SUITE 305
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-1810
Practice Address - Country:US
Practice Address - Phone:405-793-9355
Practice Address - Fax:405-912-3191
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200317340AMedicaid