Provider Demographics
NPI:1053405639
Name:HOLDER, ANGELA ELAINE (PT PHYSICAL THERAP)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:ELAINE
Last Name:HOLDER
Suffix:
Gender:F
Credentials:PT PHYSICAL THERAP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:ELAINE
Other - Last Name:VALDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:BOX 54
Mailing Address - Street 2:
Mailing Address - City:GOULD
Mailing Address - State:OK
Mailing Address - Zip Code:73544
Mailing Address - Country:US
Mailing Address - Phone:405-747-4358
Mailing Address - Fax:580-676-3951
Practice Address - Street 1:1618 NE 31ST ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3432
Practice Address - Country:US
Practice Address - Phone:405-747-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25292251P0200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200038480BMedicaid
OK200038480AMedicaid