Provider Demographics
NPI:1861823601
Name:BONAOBRA, ROGER MAGTANGOB (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:MAGTANGOB
Last Name:BONAOBRA
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 S KALANCHOE AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-0988
Mailing Address - Country:US
Mailing Address - Phone:918-286-6779
Mailing Address - Fax:
Practice Address - Street 1:3001 W BLUE STARR DR
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-2544
Practice Address - Country:US
Practice Address - Phone:918-342-1651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2192208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation