Provider Demographics
NPI:1902495260
Name:HIXON, MICHAEL CRAIG (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:HIXON
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 1:5110 S YALE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-7438
Mailing Address - Country:US
Mailing Address - Phone:918-492-2386
Mailing Address - Fax:918-645-8686
Practice Address - Street 1:825 S BIXBY ST STE B
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-5150
Practice Address - Country:US
Practice Address - Phone:918-492-2386
Practice Address - Fax:918-645-8686
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK481225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant