Provider Demographics
NPI:1649772294
Name:NEWCOMER, SHAE LEIGH
Entity Type:Individual
Prefix:
First Name:SHAE
Middle Name:LEIGH
Last Name:NEWCOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 E AVENUE G
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-3400
Mailing Address - Country:US
Mailing Address - Phone:918-413-4257
Mailing Address - Fax:
Practice Address - Street 1:1029 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4849
Practice Address - Country:US
Practice Address - Phone:918-423-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2812225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant