Healthcare Provider Details

I. General information

NPI: 1730585340
Provider Name (Legal Business Name): BETTY JO POORBOY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2014
Last Update Date: 11/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 E FAIRMONT PL
BROKEN ARROW OK
74014-8796
US

IV. Provider business mailing address

3207 E FAIRMONT PL
BROKEN ARROW OK
74014-8796
US

V. Phone/Fax

Practice location:
  • Phone: 918-521-9592
  • Fax:
Mailing address:
  • Phone: 918-521-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1847
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: