Provider Demographics
NPI:1962682104
Name:LEWIS, TARA MIRANDA (PA-C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MIRANDA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:MIRANDA
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1925 WARRIOR WAY
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3491
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:
Practice Address - Street 1:2510 CHICKASAW BLVD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1341
Practice Address - Country:US
Practice Address - Phone:580-226-8181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant