Provider Demographics
NPI:1679285811
Name:LEWALLEN, LAWRENCE CLAYTON
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:CLAYTON
Last Name:LEWALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 S BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-2804
Mailing Address - Country:US
Mailing Address - Phone:918-779-7203
Mailing Address - Fax:918-779-7244
Practice Address - Street 1:1214 S BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-2804
Practice Address - Country:US
Practice Address - Phone:918-779-7203
Practice Address - Fax:918-779-7244
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist