Provider Demographics
NPI:1639569577
Name:KOIRALA, LATA
Entity Type:Individual
Prefix:
First Name:LATA
Middle Name:
Last Name:KOIRALA
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 1:1145 S UTICA AVE
Mailing Address - Street 2:STE 460
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4041
Mailing Address - Country:US
Mailing Address - Phone:918-579-5749
Mailing Address - Fax:918-579-5762
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:SUITE 460
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4000
Practice Address - Country:US
Practice Address - Phone:918-579-5749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2483363AM0700X
TXPA12108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical