Provider Demographics
NPI:1306500186
Name:BROWN, AUSTIN LANE (PA-C)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:LANE
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11380 S 282ND EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-5013
Mailing Address - Country:US
Mailing Address - Phone:918-906-2175
Mailing Address - Fax:
Practice Address - Street 1:1725 E 19TH ST STE 800
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5464
Practice Address - Country:US
Practice Address - Phone:918-301-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant