Provider Demographics
NPI:1265910269
Name:HOLDER, LARA MADISON (NP)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:MADISON
Last Name:HOLDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:MADISON
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1265 S UTICA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4243
Mailing Address - Country:US
Mailing Address - Phone:918-592-0999
Mailing Address - Fax:918-592-1021
Practice Address - Street 1:1265 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4243
Practice Address - Country:US
Practice Address - Phone:918-592-0999
Practice Address - Fax:918-592-1021
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR103047363L00000X
OK103047363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner