Provider Demographics
NPI:1194840884
Name:ROBERTSON, JAMES WAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WAYNE
Last Name:ROBERTSON
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 1:1405 4TH AVE NW # 296
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2708
Mailing Address - Country:US
Mailing Address - Phone:580-795-4561
Mailing Address - Fax:580-226-5567
Practice Address - Street 1:1405 4TH AVE NW # 296
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2708
Practice Address - Country:US
Practice Address - Phone:580-795-4561
Practice Address - Fax:580-226-5567
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1517225200000X
OK1924225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant