MEDICARE: KRISTY DAWN WOOTEN PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	1176	OK

General Provider Information

NPI Number	:	1578781357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTY DAWN WOOTEN PTA

Provider Business Mailing Address
First Line	:	634 N CUMMINGS AVE
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006
Country	:	US
Telephone Number	:	918-876-4434
Fax Number	:

Provider Business Practice Location Address
First Line	:	2154 S 85TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-3012
Country	:	US
Telephone Number	:	918-622-4747
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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