Healthcare Provider Details

I. General information

NPI: 1356092076
Provider Name (Legal Business Name): BEAU PROCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 NW 23RD ST STE 106
OKLAHOMA CITY OK
73103-1509
US

IV. Provider business mailing address

6445 N STERLING DR
OKLAHOMA CITY OK
73132-6804
US

V. Phone/Fax

Practice location:
  • Phone: 405-613-6170
  • Fax:
Mailing address:
  • Phone: 405-613-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: