Healthcare Provider Details

I. General information

NPI: 1487086484
Provider Name (Legal Business Name): PETER MITCHELL ESTRADA DAT, LAT, ATC, BCS-O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2013
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7050 AIR DEPOT BLVD
TINKER AFB OK
73145-8716
US

IV. Provider business mailing address

7209 JACK DR
OKLAHOMA CITY OK
73132-4809
US

V. Phone/Fax

Practice location:
  • Phone: 405-734-9595
  • Fax:
Mailing address:
  • Phone: 405-546-0986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT5394
License Number StateTX

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: