Provider Demographics
NPI:1922317247
Name:FOSTER, BRANDON WAYNE (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WAYNE
Last Name:FOSTER
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 1:26300 S HIGHWAY 125
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:OK
Mailing Address - Zip Code:74331-6282
Mailing Address - Country:US
Mailing Address - Phone:918-256-0362
Mailing Address - Fax:918-257-8688
Practice Address - Street 1:26300 S HIGHWAY 125
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:OK
Practice Address - Zip Code:74331-6282
Practice Address - Country:US
Practice Address - Phone:918-256-0362
Practice Address - Fax:918-257-8688
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1833225200000X
MO2009032388225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant