Provider Demographics
NPI:1649584855
Name:HUMPHREY, LEA SARAH (DO)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:SARAH
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MERCY WAY
Mailing Address - Street 2:STE 560
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4524
Mailing Address - Country:US
Mailing Address - Phone:417-556-8555
Mailing Address - Fax:417-556-8553
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4133
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:918-453-9107
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010019023207YX0905X
OK6819207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200593430AMedicaid