Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2622 | OK |
NPI | 1013507441 |
---|---|
Provider Name | Kathren Green |
First Address | Broken Arrow, OK 74012-3628 |
Second Address | Broken Arrow, OK 74012-3628 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/01/2021 |
Last Update Date | 20/01/2021 |