Healthcare Provider Details

I. General information

NPI: 1255903761
Provider Name (Legal Business Name): PAIGE M BRADLEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4008 S YALE AVE
TULSA OK
74135-6017
US

IV. Provider business mailing address

PO BOX 721018
NORMAN OK
73070-4786
US

V. Phone/Fax

Practice location:
  • Phone: 918-622-4278
  • Fax:
Mailing address:
  • Phone: 405-809-8713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3419
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: