Provider Demographics
NPI:1073182903
Name:EIDSON, JASON WAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WAYNE
Last Name:EIDSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-4203
Mailing Address - Country:US
Mailing Address - Phone:580-651-0783
Mailing Address - Fax:
Practice Address - Street 1:211 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-4203
Practice Address - Country:US
Practice Address - Phone:580-651-0783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2883225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant