Provider Demographics
NPI:1407057243
Name:THOMSON, KEITH BRADLEY (MED, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:BRADLEY
Last Name:THOMSON
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-3126
Mailing Address - Country:US
Mailing Address - Phone:918-232-2208
Mailing Address - Fax:
Practice Address - Street 1:600 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-3126
Practice Address - Country:US
Practice Address - Phone:918-631-5423
Practice Address - Fax:918-631-3057
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4332255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer