Provider Demographics
NPI:1841873692
Name:WIGINTON, SHADERA (PTA)
Entity type:Individual
Prefix:MRS
First Name:SHADERA
Middle Name:
Last Name:WIGINTON
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 1:3801 24TH AVE SE APT 12
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-0800
Mailing Address - Country:US
Mailing Address - Phone:405-596-7148
Mailing Address - Fax:
Practice Address - Street 1:3801 24TH AVE SE APT 12
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-0800
Practice Address - Country:US
Practice Address - Phone:405-596-7148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1417225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant