MEDICARE: KRISTIE HODGES PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2016	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2016	OTHER	OK	PTA LICENSE

General Provider Information

NPI Number	:	1144805565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIE HODGES PTA

Provider Business Mailing Address
First Line	:	440 MERCHANT DR
Second Line	:
City	:	NORMAN
State	:	OK
Zip	:	73069-6470
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1124 S DOUGLAS BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-5236
Country	:	US
Telephone Number	:	405-582-2105
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2021
Last Update Date	:	03/17/2021

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