Basic Information
| Provider Information | |||||||||
| NPI: | 1427251818 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARNER | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | GPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4812 E 33RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224126 | ||||||||
| FaxNumber: | 9182702398 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 E ROGERS BLVD | ||||||||
| Address2: | |||||||||
| City: | SKIATOOK | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740701251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183969799 | ||||||||
| FaxNumber: | 9183969891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 04/22/2014 | ||||||||
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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 | 225100000X | 4034 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200117540A | 05 | OK | MEDICAID |