Provider Demographics
NPI:1710903604
Name:ISENBERG, LAURIE LEIGH (PA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:LEIGH
Last Name:ISENBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7333 E 121ST ST S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-2654
Mailing Address - Country:US
Mailing Address - Phone:918-403-7140
Mailing Address - Fax:918-856-5392
Practice Address - Street 1:7333 E 121ST ST S
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008
Practice Address - Country:US
Practice Address - Phone:918-403-7140
Practice Address - Fax:918-856-5392
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1342363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q15250Medicare UPIN