Provider Demographics
NPI:1245662550
Name:SHARP, JACE EVAN (DPT)
Entity type:Individual
Prefix:
First Name:JACE
Middle Name:EVAN
Last Name:SHARP
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-4624
Mailing Address - Country:US
Mailing Address - Phone:918-485-1212
Mailing Address - Fax:918-485-1335
Practice Address - Street 1:1200 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4624
Practice Address - Country:US
Practice Address - Phone:918-485-1212
Practice Address - Fax:918-485-1335
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200513580AMedicaid
OK311943YUQZMedicare PIN