MEDICARE: TINA E TAKEN 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	171W00000X	Contractor	TA218	OK

General Provider Information

NPI Number	:	1881812618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA E TAKEN PTA

Provider Business Mailing Address
First Line	:	134 NE 21ST ST
Second Line	:
City	:	MOORE
State	:	OK
Zip	:	73160-4410
Country	:	US
Telephone Number	:	405-923-0069
Fax Number	:

Provider Business Practice Location Address
First Line	:	6525 N MERIDIAN AVE
Second Line	:	SUITE 311
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73116-1420
Country	:	US
Telephone Number	:	405-721-1115
Fax Number	:

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/08/2007

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Directions to “ TINA E TAKEN PTA” Practice Location

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