Basic Information
| Provider Information | |||||||||
| NPI: | 1447683701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAHPEPAH | ||||||||
| FirstName: | KRISTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2029 S GORDON COOPER DR | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748019005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058785850 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 STONECIPHER BLVD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748203270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214570 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2013 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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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 | 4676 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 4676 | 01 | OK | LICENSE NUMBER | OTHER |