Provider Demographics
NPI:1780862946
Name:STEWART, KEVIN (PTA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:STEWART
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 W LINCOLN
Mailing Address - Street 2:
Mailing Address - City:CORN
Mailing Address - State:OK
Mailing Address - Zip Code:73024-9605
Mailing Address - Country:US
Mailing Address - Phone:580-744-0086
Mailing Address - Fax:
Practice Address - Street 1:2316 W MODELLE AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3722
Practice Address - Country:US
Practice Address - Phone:580-323-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-09
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1237225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant