Provider Demographics
NPI:1821366543
Name:FLEMING, MATT KENNETH (PTA)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:KENNETH
Last Name:FLEMING
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 LERA DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096
Mailing Address - Country:US
Mailing Address - Phone:580-772-3200
Mailing Address - Fax:580-772-1061
Practice Address - Street 1:1400 LERA
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:OK
Practice Address - Zip Code:73096-2629
Practice Address - Country:US
Practice Address - Phone:580-772-3200
Practice Address - Fax:580-772-1061
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2025174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist