Provider Demographics
NPI:1467782094
Name:HARRISON, AMY (PA)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:LOVELACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:717 S HOUSTON AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9023
Mailing Address - Country:US
Mailing Address - Phone:918-382-5064
Mailing Address - Fax:918-382-3589
Practice Address - Street 1:717 S HOUSTON AVE STE 304
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9023
Practice Address - Country:US
Practice Address - Phone:918-382-5064
Practice Address - Fax:918-382-3589
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200274280AMedicaid