Provider Demographics
NPI:1316420086
Name:WILSON, LAUREN (MMS, PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:MISS
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:ANTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS, PA-C
Mailing Address - Street 1:7430 NE HAWK DRIVE
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6729 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2605
Practice Address - Country:US
Practice Address - Phone:405-491-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2959363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical