=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982294310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLIE MADISON APPLEGATE PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2021
-----------------------------------------------------
Last Update Date | 01/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6715 E 41ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74145-4520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-806-0106
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19611 S 397TH EAST AVE
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74454-5919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-616-1884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P0010X
-----------------------------------------------------
Taxonomy Name | Pediatric Rehabilitation Medicine Physician
-----------------------------------------------------
License Number | 3113
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 3113
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------