Provider Demographics
NPI:1700263928
Name:LUPOV, MICAELA (PA)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:
Last Name:LUPOV
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 1:1145 S UTICA AVE
Mailing Address - Street 2:STE 460
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4000
Mailing Address - Country:US
Mailing Address - Phone:918-579-5749
Mailing Address - Fax:918-560-5791
Practice Address - Street 1:101 N ROBINSON AVE STE 200
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102
Practice Address - Country:US
Practice Address - Phone:405-271-8880
Practice Address - Fax:405-208-8732
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
OK2497363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100748790AMedicaid
OK400522144Medicare PIN