Provider Demographics
NPI:1558339184
Name:GREEN, LARA E (PA-C)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:405-307-6668
Mailing Address - Fax:405-701-6170
Practice Address - Street 1:2821 36TH AVE NW STE 105
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-2471
Practice Address - Country:US
Practice Address - Phone:405-515-2049
Practice Address - Fax:405-307-5631
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1235363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200063470AMedicaid
P88093Medicare UPIN
OK24R531907Medicare ID - Type Unspecified