Basic Information
| Provider Information | |||||||||
| NPI: | 1578672176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | MONTY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 TRAIL RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | SAPULPA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740669314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187701798 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 E 141ST ST | ||||||||
| Address2: | |||||||||
| City: | GLENPOOL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740333524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183223884 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200132790A | 05 | OK | MEDICAID | 3848 | 01 | OK | LICENSE # | OTHER |