Provider Demographics
NPI:1356092076
Name:PROCTOR, BEAU
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6445 N STERLING DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-6804
Mailing Address - Country:US
Mailing Address - Phone:405-613-6170
Mailing Address - Fax:
Practice Address - Street 1:519 NW 23RD ST STE 106
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-1509
Practice Address - Country:US
Practice Address - Phone:405-613-6170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty