Basic Information
| Provider Information | |||||||||
| NPI: | 1063566818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MISNER | ||||||||
| FirstName: | KARISSA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1216 E KENOSHA ST | ||||||||
| Address2: | PMB 326 | ||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740122007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186156581 | ||||||||
| FaxNumber: | 9188931242 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 ROCKEFELLER DR | ||||||||
| Address2: | REHABILITATION UNIT | ||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744015075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186842522 | ||||||||
| FaxNumber: | 9186842493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 12/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4643 | OK | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208M00000X | 4643 | OK | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 200215510A | 05 | OK | MEDICAID |