Provider Demographics
NPI:1003876673
Name:LA SORSA, ANTHONY JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:LA SORSA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4417 W GORE BLVD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5978
Mailing Address - Country:US
Mailing Address - Phone:580-353-9399
Mailing Address - Fax:580-353-2624
Practice Address - Street 1:4417 W GORE BLVD
Practice Address - Street 2:SUITE 14
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5978
Practice Address - Country:US
Practice Address - Phone:580-353-9399
Practice Address - Fax:580-353-2624
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKPT2929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5795900001Medicare NSC
OK244629307Medicare PIN