Provider Demographics
NPI:1336779206
Name:LAZENBY, JOHN NELSON III (MHS, PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:NELSON
Last Name:LAZENBY
Suffix:III
Gender:M
Credentials:MHS, PA-C
Other - Prefix:
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Mailing Address - Street 1:6708 TREVI CT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-2604
Mailing Address - Country:US
Mailing Address - Phone:580-695-2958
Mailing Address - Fax:
Practice Address - Street 1:4 E CLARK BASS BLVD STE 302
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4269
Practice Address - Country:US
Practice Address - Phone:918-426-4306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK3133363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty