Provider Demographics
NPI:1245472059
Name:BLACK, ALYSSA CREWS (PA)
Entity type:Individual
Prefix:MRS
First Name:ALYSSA
Middle Name:CREWS
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:NICOLE
Other - Last Name:CREWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6161 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-1902
Mailing Address - Country:US
Mailing Address - Phone:918-502-3939
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-502-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant