Provider Demographics
NPI:1558730242
Name:HINES- LAWSON, CARISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:HINES- LAWSON
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 1:12142 S YUKON AVE
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-6621
Mailing Address - Country:US
Mailing Address - Phone:918-935-3636
Mailing Address - Fax:
Practice Address - Street 1:12142 S YUKON AVE
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-6621
Practice Address - Country:US
Practice Address - Phone:918-935-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2568363A00000X, 363AM0700X
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical