Provider Demographics
NPI:1386677995
Name:HARJO, LUCILLE JEANNETTE (PA - C)
Entity Type:Individual
Prefix:
First Name:LUCILLE
Middle Name:JEANNETTE
Last Name:HARJO
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:JEANNETTE
Other - Middle Name:
Other - Last Name:HARJO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-0400
Mailing Address - Country:US
Mailing Address - Phone:918-756-3334
Mailing Address - Fax:918-756-3993
Practice Address - Street 1:1125 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4641
Practice Address - Country:US
Practice Address - Phone:918-224-9310
Practice Address - Fax:918-756-3993
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK535363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1691535Medicaid
OK1691535Medicaid
OKPA005351Medicare ID - Type UnspecifiedSAPULPA