Healthcare Provider Details

I. General information

NPI: 1376063065
Provider Name (Legal Business Name): BRANDON ATKINS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7019 NW CACHE RD
LAWTON OK
73505-2707
US

IV. Provider business mailing address

2 NW 69TH ST
LAWTON OK
73505-5302
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-1279
  • Fax:
Mailing address:
  • Phone: 479-301-3378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2596
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: