Healthcare Provider Details

I. General information

NPI: 1639373574
Provider Name (Legal Business Name): RYAN DOUGLAS ADE P.T., A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 N 10TH ST
FREDERICK OK
73542-1421
US

IV. Provider business mailing address

800 NW 6TH ST
OKLAHOMA CITY OK
73106-7241
US

V. Phone/Fax

Practice location:
  • Phone: 580-335-6642
  • Fax: 580-335-6607
Mailing address:
  • Phone: 405-609-3667
  • Fax: 580-609-3697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number431
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3077
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: