Provider Demographics
NPI:1205568854
Name:KINNAMON, ANDREW WILLIAM (PT)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WILLIAM
Last Name:KINNAMON
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 1:9060 HARMONY DR
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-6218
Mailing Address - Country:US
Mailing Address - Phone:405-610-8090
Mailing Address - Fax:405-610-8097
Practice Address - Street 1:9060 HARMONY DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-6218
Practice Address - Country:US
Practice Address - Phone:405-610-8090
Practice Address - Fax:405-610-8097
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist