Healthcare Provider Details

I. General information

NPI: 1114360708
Provider Name (Legal Business Name): WYNONA A LUTZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2013
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E COMANCHE AVE
MCALESTER OK
74501-5845
US

IV. Provider business mailing address

221 E COMANCHE AVE
MCALESTER OK
74501-5845
US

V. Phone/Fax

Practice location:
  • Phone: 918-423-1181
  • Fax: 918-423-1191
Mailing address:
  • Phone: 918-423-1181
  • Fax: 918-423-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2229
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2660
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: