Healthcare Provider Details

I. General information

NPI: 1417863143
Provider Name (Legal Business Name): PETER JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4008 S YALE AVE
TULSA OK
74135-6017
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 918-622-4278
  • Fax: 918-622-4844
Mailing address:
  • Phone: 726-202-3039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7168
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: