Healthcare Provider Details

I. General information

NPI: 1932939550
Provider Name (Legal Business Name): MICHAEL KENICHI OKIKAWA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DR
JBSA FT SAM HOUSTON TX
78234-4501
US

IV. Provider business mailing address

3851 ROGER BROOKE DR
SAN ANTONIO TX
78234-4501
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-5048
  • Fax:
Mailing address:
  • Phone: 210-916-5048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2064040
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: