Basic Information
| Provider Information | |||||||||
| NPI: | 1003036799 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANTNER | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | THACKER | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4505 E 103RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741375946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184941443 | ||||||||
| FaxNumber: | 9184941494 | ||||||||
| Practice Location | |||||||||
| Address1: | 6161 S YALE AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184941471 | ||||||||
| FaxNumber: | 9184941494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT1123 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.