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NPI Code Detail

MEDICARE: KRYSTAL HARRISON PTA

MEDICARE: KRYSTAL HARRISON 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
1225200000XPhysical Therapy Assistant1558OK

General Provider Information

NPI Number : 1790029122
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRYSTAL HARRISON PTA
Provider Business Mailing Address
First Line : 1601 ACADEMY RD
Second Line :
City : PONCA CITY
State : OK
Zip : 74604-4409
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1601 ACADEMY RD
Second Line :
City : PONCA CITY
State : OK
Zip : 74604-4409
Country : US
Telephone Number : 580-762-0927
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/26/2012
Last Update Date : 11/26/2012

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Directions to “ KRYSTAL HARRISON PTA” Practice Location

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