Healthcare Provider Details

I. General information

NPI: 1245973080
Provider Name (Legal Business Name): KIRSTA BOWLES PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5117 W GORE BLVD
LAWTON OK
73505-5998
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 580-355-6785
  • Fax: 580-355-6788
Mailing address:
  • Phone: 405-609-3667
  • Fax: 405-609-3697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2609
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: