Basic Information
| Provider Information | |||||||||
| NPI: | 1063474344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LONNIE | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2115 PARKVIEW DR | ||||||||
| Address2: | |||||||||
| City: | EL RENO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730362109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052951166 | ||||||||
| FaxNumber: | 4052951334 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 W MEMORIAL RD | ||||||||
| Address2: | ER DEPT. | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057523715 | ||||||||
| FaxNumber: | 4059365058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 698 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100117880B | 05 | OK | MEDICAID | 100117880A | 05 | OK | MEDICAID |