Provider Demographics
NPI:1477139301
Name:COOK, AMANDA W (LPTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:W
Last Name:COOK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31450 S 616 RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-6003
Mailing Address - Country:US
Mailing Address - Phone:918-964-9994
Mailing Address - Fax:
Practice Address - Street 1:2203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5329
Practice Address - Country:US
Practice Address - Phone:918-786-3797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2571208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation