Provider Demographics
NPI:1902090947
Name:BONAOBRA, AMY RESULTAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:RESULTAN
Last Name:BONAOBRA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 W EL PASO ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-4556
Mailing Address - Country:US
Mailing Address - Phone:918-249-1962
Mailing Address - Fax:
Practice Address - Street 1:6600 S YALE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3310
Practice Address - Country:US
Practice Address - Phone:918-488-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist