Basic Information
| Provider Information | |||||||||
| NPI: | 1679980601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | JEANETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 LINDA LN | ||||||||
| Address2: | |||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730991615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052026738 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3030 NW EXPRESSWAY | ||||||||
| Address2: | SUITE 809 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059177160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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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 | 225200000X | 1064 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.