Provider Demographics
NPI:1568034767
Name:ROBERTS, HUNTER KRISTIAN (PTA)
Entity Type:Individual
Prefix:
First Name:HUNTER
Middle Name:KRISTIAN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27427 E 109TH ST S
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-3442
Mailing Address - Country:US
Mailing Address - Phone:918-618-3873
Mailing Address - Fax:
Practice Address - Street 1:701 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5528
Practice Address - Country:US
Practice Address - Phone:918-259-5784
Practice Address - Fax:918-251-0689
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3354225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1669580502Medicaid