Basic Information
| Provider Information | |||||||||
| NPI: | 1841568060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TA | ||||||||
| FirstName: | MY | ||||||||
| MiddleName: | CHUONG | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BS, PT, MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 SW 122ND ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731704855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056206413 | ||||||||
| FaxNumber: | 4057523191 | ||||||||
| Practice Location | |||||||||
| Address1: | 3328 N CLASSEN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731183428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055245200 | ||||||||
| FaxNumber: | 4055245206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2011 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 3619 | OK | Y | Other Service Providers | Specialist |
No ID Information.