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General NPI Number Information
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NPI Number | 1861069379
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Entity Type | Individual
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Provider Name | ALAN DWAYNE STATUM OTA
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Gender | Male
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Dates
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Enumeration Date | 06/04/2021
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Last Update Date | 06/04/2021
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Provider Practice Location Address
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Address Line | 8720 S. 101ST AVE
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City | TULSA
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State | OK
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Zip | 74133
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Country | US
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Telephone | 918-965-0101
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Fax |
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Provider Business Mailing Address
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Address Line | 412 E BEAVER ST
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City | JENKS
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State | OK
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Zip | 74037-4513
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Country | US
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Telephone | 918-637-4790
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number |
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License Number State | OK
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