MEDICARE: KENNEDY ANDERSON 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	3241	OK

General Provider Information

NPI Number	:	1689274961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNEDY ANDERSON PTA

Provider Business Mailing Address
First Line	:	1309 E WADE WATTS AVE
Second Line	:
City	:	MCALESTER
State	:	OK
Zip	:	74501-5658
Country	:	US
Telephone Number	:	918-423-2220
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 E WADE WATTS AVE
Second Line	:
City	:	MCALESTER
State	:	OK
Zip	:	74501-5658
Country	:	US
Telephone Number	:	918-423-2220
Fax Number	:

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

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	08/15/2025

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