Basic Information
| Provider Information | |||||||||
| NPI: | 1952733073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITTEN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | FOSTER | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6475 S YALE AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741367816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184949300 | ||||||||
| FaxNumber: | 9184949355 | ||||||||
| Practice Location | |||||||||
| Address1: | 6475 S YALE AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741367816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184949300 | ||||||||
| FaxNumber: | 9184949355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2013 | ||||||||
| LastUpdateDate: | 05/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 772 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 772 | 01 | OK | OKLAHOMA STATE ATHLETIC TRAINING LICENSE NUMBER | OTHER |