Provider Demographics
NPI:1780915413
Name:LAMB, JEREMY BRANDON (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:BRANDON
Last Name:LAMB
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 JAXON CT
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-7713
Mailing Address - Country:US
Mailing Address - Phone:405-473-2035
Mailing Address - Fax:
Practice Address - Street 1:2318 SE 44TH ST
Practice Address - Street 2:
Practice Address - City:NEWCASTLE
Practice Address - State:OK
Practice Address - Zip Code:73065-4702
Practice Address - Country:US
Practice Address - Phone:450-387-9323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant