Healthcare Provider Details

I. General information

NPI: 1710661731
Provider Name (Legal Business Name): MICAH OWNBEY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 NW 23RD ST STE 2D
OKLAHOMA CITY OK
73107-2420
US

IV. Provider business mailing address

11032 NW 114TH ST
YUKON OK
73099-8041
US

V. Phone/Fax

Practice location:
  • Phone: 405-355-3239
  • Fax:
Mailing address:
  • Phone: 405-313-7890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: