Provider Demographics
NPI:1669668042
Name:WOLFE, MASTON BRADLEY III (MPT)
Entity Type:Individual
Prefix:MR
First Name:MASTON
Middle Name:BRADLEY
Last Name:WOLFE
Suffix:III
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6525 N MERIDIAN AVE
Mailing Address - Street 2:SUITE 311
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1420
Mailing Address - Country:US
Mailing Address - Phone:405-721-1115
Mailing Address - Fax:405-728-1115
Practice Address - Street 1:6525 N MERIDIAN AVE
Practice Address - Street 2:SUITE 311
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1420
Practice Address - Country:US
Practice Address - Phone:405-721-1115
Practice Address - Fax:405-728-1115
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4004261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy