Provider Demographics
NPI:1881693414
Name:KIPPENBERGER, LISA DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:KIPPENBERGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:HIGHTOWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9600 BROADWAY EXT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7408
Mailing Address - Country:US
Mailing Address - Phone:405-486-2140
Mailing Address - Fax:405-486-2574
Practice Address - Street 1:9600 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7408
Practice Address - Country:US
Practice Address - Phone:405-486-2140
Practice Address - Fax:405-486-2574
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100096810AMedicaid
OK970015207OtherRAILROAD MEDICARE
P09793Medicare UPIN
OKPA00977Medicare ID - Type Unspecified