Provider Demographics
NPI:1619208063
Name:PROMMART, MANOTE
Entity Type:Individual
Prefix:MR
First Name:MANOTE
Middle Name:
Last Name:PROMMART
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MANOTE
Other - Middle Name:
Other - Last Name:PROMMART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1101 S 33RD ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2929
Mailing Address - Country:US
Mailing Address - Phone:918-497-8806
Mailing Address - Fax:
Practice Address - Street 1:1101 S 33RD ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2929
Practice Address - Country:US
Practice Address - Phone:918-497-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708360BMedicaid