Basic Information
| Provider Information | |||||||||
| NPI: | 1386307791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JOHNATHAN | ||||||||
| MiddleName: | ADAM | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 745712022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | 9185677119 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | 9185677119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2021 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 1197 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.