=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558996702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP DAVID WHETSTONE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2020
-----------------------------------------------------
Last Update Date | 03/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 ACADEMY RD
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74604-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-762-0927
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3753 N 108TH ST
-----------------------------------------------------
City | NARDIN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74646-5072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-363-8560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT-2343
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------