Provider Demographics
NPI:1255745071
Name:BROWN, JOHN (PTA, CSCS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:PTA, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1633 S VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3901
Mailing Address - Country:US
Mailing Address - Phone:580-364-7090
Mailing Address - Fax:
Practice Address - Street 1:1633 S VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3901
Practice Address - Country:US
Practice Address - Phone:580-364-7090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-19
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2841225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant