MEDICARE: KERI DAWN VANDERPOOL 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	TA583	OK

General Provider Information

NPI Number	:	1649481789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERI DAWN VANDERPOOL PTA

Provider Business Mailing Address
First Line	:	1105 S MARINA DR
Second Line	:
City	:	OOLOGAH
State	:	OK
Zip	:	74053-3284
Country	:	US
Telephone Number	:	918-443-2026
Fax Number	:	917-443-2026

Provider Business Practice Location Address
First Line	:	4815 S HARVARD AVE
Second Line	:	SUITE 455
City	:	TULSA
State	:	OK
Zip	:	74135-3055
Country	:	US
Telephone Number	:	918-712-7805
Fax Number	:

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	07/08/2007

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