Provider Demographics
NPI:1639568942
Name:TOMICHEN, LIZ
Entity Type:Individual
Prefix:
First Name:LIZ
Middle Name:
Last Name:TOMICHEN
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 1:2017 W I 35 FRONTAGE RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-8550
Mailing Address - Country:US
Mailing Address - Phone:405-757-3365
Mailing Address - Fax:405-757-3366
Practice Address - Street 1:2017 W I 35 FRONTAGE RD
Practice Address - Street 2:SUITE 170
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-8550
Practice Address - Country:US
Practice Address - Phone:405-757-3365
Practice Address - Fax:405-757-3366
Is Sole Proprietor?:No
Enumeration Date:2015-01-10
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant