Provider Demographics
NPI:1588150312
Name:ERNST, CAMPBELL WARD (MAT, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:CAMPBELL
Middle Name:WARD
Last Name:ERNST
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 S GRANITE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5557
Mailing Address - Country:US
Mailing Address - Phone:918-407-7703
Mailing Address - Fax:
Practice Address - Street 1:3901 S GRANITE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5557
Practice Address - Country:US
Practice Address - Phone:918-407-7703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT75562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer