Provider Demographics
NPI:1063566743
Name:NOE, LISA DIANE (PA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANE
Last Name:NOE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1030 E CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4102
Mailing Address - Country:US
Mailing Address - Phone:918-225-0616
Mailing Address - Fax:918-225-3740
Practice Address - Street 1:1030 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4102
Practice Address - Country:US
Practice Address - Phone:918-225-0616
Practice Address - Fax:918-225-3740
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1499363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200075990AMedicaid
OK200075990AMedicaid