Provider Demographics
NPI:1679980601
Name:MARTIN, ANGIE JEANETTE (PTA)
Entity type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:JEANETTE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:205 LINDA LN
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-1615
Mailing Address - Country:US
Mailing Address - Phone:405-202-6738
Mailing Address - Fax:
Practice Address - Street 1:3030 NW EXPRESSWAY
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:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1064225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant