Provider Demographics
NPI:1942061700
Name:LIDDELL, RYAN ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:ELIZABETH
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5593 E 470 RD
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-1104
Mailing Address - Country:US
Mailing Address - Phone:417-771-9333
Mailing Address - Fax:
Practice Address - Street 1:13600 E 86TH ST N STE 100
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-8732
Practice Address - Country:US
Practice Address - Phone:918-272-9313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant