Provider Demographics
NPI:1891939716
Name:FUKSA, KEITH JAMES (PT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:FUKSA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 W RANDOLPH AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-3826
Mailing Address - Country:US
Mailing Address - Phone:580-234-1115
Mailing Address - Fax:580-234-1150
Practice Address - Street 1:723 W RANDOLPH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-3826
Practice Address - Country:US
Practice Address - Phone:580-234-1115
Practice Address - Fax:580-234-1150
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist