Healthcare Provider Details

I. General information

NPI: 1700242344
Provider Name (Legal Business Name): JONATHAN DAVID MCMASTERS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E PECAN ST
ALTUS OK
73521-6141
US

IV. Provider business mailing address

1200 E PECAN ST
ALTUS OK
73521-6141
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-5820
  • Fax: 580-379-5829
Mailing address:
  • Phone: 580-379-5820
  • Fax: 580-379-5829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2573
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: