MEDICARE: BLAKE ALLEN

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	3604	OK

General Provider Information

NPI Number	:	1619773082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE ALLEN

Provider Business Mailing Address
First Line	:	10703 N GARNETT RD APT E101
Second Line	:
City	:	OWASSO
State	:	OK
Zip	:	74055-8966
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3701 N MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74106-6450
Country	:	US
Telephone Number	:	918-425-3583
Fax Number	:

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

Provider Enumeration Date	:	02/24/2025
Last Update Date	:	02/24/2025

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Directions to “ BLAKE ALLEN ” Practice Location

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