Basic Information
| Provider Information | |||||||||
| NPI: | 1700971405 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLASS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | G | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 PATTI CIR | ||||||||
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| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744644021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583100 | ||||||||
| FaxNumber: | 9184583511 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 S BLISS AVE | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744642512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184583100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246W00000X | X | Technologists, Technicians & Other Technical Service Providers | Technician, Cardiology | 246ZE0600X | X | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.