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General NPI Number Information
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NPI Number | 1902035207
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Entity Type | Individual
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Provider Name | MICAH JEROD LITTLEJOHN PTA
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Gender | Male
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Dates
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Enumeration Date | 07/08/2009
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Last Update Date | 07/08/2009
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Provider Practice Location Address
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Address Line | 715 N BREWER ST
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City | VINITA
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State | OK
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Zip | 74301-1426
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Country | US
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Telephone | 918-256-9207
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Fax |
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Provider Business Mailing Address
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Address Line | 616 MEADOWLARK LN
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City | COMMERCE
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State | OK
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Zip | 74339-3147
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Country | US
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Telephone | 918-533-4292
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 1741
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License Number State | OK
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