Individual
GAE CAPERS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.T.
Contact information
Practice address
4812 E 33RD ST, TULSA, OK 74135-2038
(918) 622-4126
(918) 270-2398
Mailing address
4812 E 33RD ST, TULSA, OK 74135-2038
(918) 622-4126
(918) 270-2398
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2574
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
200064620A
MEDICAID LEGACY
OK
05
—
200064620A
—
OK
01
—
248508015
MEDICARE LEGACY
OK
01
—
7735612
AETNA
OK
01
—
P00291955
MEDICARE RAILROAD
OK
Enumeration date
10/12/2005
Last updated
06/20/2012
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