Basic Information
| Provider Information | |||||||||
| NPI: | 1912995994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | P.T. | ||||||||
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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: | 4812 E 33RD ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186224126 | ||||||||
| FaxNumber: | 9182702398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2006 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 20034530A | 05 | OK | MEDICAID | 4533856 | 01 | AETNA LEGACY | OTHER | 200034530A | 01 | MEDICAID LEGACY | OTHER | 650021945 | 01 | MEDICARE RAILROAD | OTHER |