Provider Demographics
NPI:1013027275
Name:PACK, PATRICIA (PT)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:PACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 60 BOX 205
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426-9408
Mailing Address - Country:US
Mailing Address - Phone:918-473-8249
Mailing Address - Fax:918-683-4002
Practice Address - Street 1:1111 N 36TH ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1809
Practice Address - Country:US
Practice Address - Phone:918-683-4621
Practice Address - Fax:918-683-4002
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK4252081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK510163643001OtherBLUE CROSS/ BLUE SHIELD