Healthcare Provider Details

I. General information

NPI: 1417502790
Provider Name (Legal Business Name): ANDREW SENA NFODJO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 E 81ST ST STE 290
TULSA OK
74137-4299
US

IV. Provider business mailing address

2488 E 81ST ST STE 290
TULSA OK
74137-4299
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2665
  • Fax: 918-927-3201
Mailing address:
  • Phone: 918-494-2665
  • Fax: 918-927-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1301719
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number124657
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: