Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 2010019023 | MO |
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 6819 | OK |
NPI | 1649584855 |
---|---|
Provider Name | Lea Sarah Humphrey |
First Address | Joplin, MO 64804-4524 |
Second Address | Tahlequah, OK 74464-4133 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2010 |
Last Update Date | 04/10/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200593430A | (05) | OK |