Provider Demographics
NPI:1336158898
Name:MACDONALD, KERRY R (MPT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:R
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-4472
Mailing Address - Country:US
Mailing Address - Phone:580-558-3414
Mailing Address - Fax:
Practice Address - Street 1:4301 WILSON ST
Practice Address - Street 2:
Practice Address - City:FORT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503-4472
Practice Address - Country:US
Practice Address - Phone:805-558-3414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2962225100000X
OK4647225100000X
TX1129815225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13602012Medicaid
NMNM00Q469OtherBCBS NM