Provider Demographics
NPI:1720284201
Name:OLDHAM, VIRGINIA IRENE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:IRENE
Last Name:OLDHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 S MUSTANG RD
Mailing Address - Street 2:#512
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-0306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 NW EXPRESSWAY ST
Practice Address - Street 2:SUITE 809
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5474
Practice Address - Country:US
Practice Address - Phone:405-917-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1487225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant