Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 182962 | OK |
NPI | 1013543719 |
---|---|
Provider Name | Adrian Lamar Prophet |
First Address | Moore, OK 73160-6744 |
Second Address | Edmond, OK 73013-3642 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2020 |
Last Update Date | 14/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
182962 | MASSAGE THERAPIST (01) | OK |