Provider Demographics
NPI:1902572274
Name:FOWLER, LEISHA RAE (PTA)
Entity Type:Individual
Prefix:
First Name:LEISHA
Middle Name:RAE
Last Name:FOWLER
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 1:3345 S HARVARD AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-1815
Mailing Address - Country:US
Mailing Address - Phone:318-574-2575
Mailing Address - Fax:
Practice Address - Street 1:3345 S HARVARD AVE STE 301
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-1815
Practice Address - Country:US
Practice Address - Phone:918-574-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3444225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant