Provider Demographics
NPI:1629315106
Name:MCENTIRE, LISA LARAE
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:LARAE
Last Name:MCENTIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-0267
Mailing Address - Country:US
Mailing Address - Phone:580-221-0781
Mailing Address - Fax:
Practice Address - Street 1:3120 CARTER RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-0267
Practice Address - Country:US
Practice Address - Phone:580-221-0781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist