Healthcare Provider Details

I. General information

NPI: 1558080374
Provider Name (Legal Business Name): BRANTLEY LAWSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MERCHANT DR
NORMAN OK
73069-6470
US

IV. Provider business mailing address

440 MERCHANT DR
NORMAN OK
73069-6470
US

V. Phone/Fax

Practice location:
  • Phone: 405-579-1600
  • Fax:
Mailing address:
  • Phone: 405-809-8713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3616
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: