Basic Information
| Provider Information | |||||||||
| NPI: | 1720284201 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLDHAM | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | IRENE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 S MUSTANG RD | ||||||||
| Address2: | #512 | ||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730990306 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3030 NW EXPRESSWAY ST | ||||||||
| Address2: | SUITE 809 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059177160 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| 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 | 225200000X | 1487 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.