MEDICARE: DR. KYLE WOMACK PT, DPT

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	225100000X	Physical Therapist	PT4020	HI
2	2251S0007X	Sports Physical Therapist	4951	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER		N/A

General Provider Information

NPI Number	:	1487036844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE WOMACK PT, DPT

Provider Business Mailing Address
First Line	:	1213 SW 18TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73108-7217
Country	:	US
Telephone Number	:	405-641-6263
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 N BROADWAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73103-4609
Country	:	US
Telephone Number	:	405-633-0193
Fax Number	:

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

Provider Enumeration Date	:	06/22/2015
Last Update Date	:	04/30/2024

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