Basic Information
| Provider Information | |||||||||
| NPI: | 1417498684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMULLEN | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZALVIDAR | ||||||||
| OtherFirstName: | MISTY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6585 S YALE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741368315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184812767 | ||||||||
| FaxNumber: | 9184949277 | ||||||||
| Practice Location | |||||||||
| Address1: | 13720 E 86TH ST N | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740558704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186098088 | ||||||||
| FaxNumber: | 9186098089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 1453 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.