Provider Demographics
NPI:1477922599
Name:CROSS, CARRIE IRENE (PA)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:IRENE
Last Name:CROSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:CARRIE
Other - Middle Name:IRENE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:220 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3701
Mailing Address - Country:US
Mailing Address - Phone:918-403-7144
Mailing Address - Fax:918-856-5561
Practice Address - Street 1:220 S ELM ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3701
Practice Address - Country:US
Practice Address - Phone:918-403-7144
Practice Address - Fax:918-856-5561
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant