Provider Demographics
NPI:1588380679
Name:MCREYNOLDS, BRENT M SR (PTA)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:M
Last Name:MCREYNOLDS
Suffix:SR
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:JEFFERSON COUNTY HOSPITAL
Mailing Address - Street 2:9170 US HWY 70
Mailing Address - City:WAURIKA
Mailing Address - State:OK
Mailing Address - Zip Code:73573
Mailing Address - Country:US
Mailing Address - Phone:580-228-2344
Mailing Address - Fax:
Practice Address - Street 1:JEFFERSON COUNTY HOSPITAL
Practice Address - Street 2:9170 US HWY 70
Practice Address - City:WAURIKA
Practice Address - State:OK
Practice Address - Zip Code:73573-7357
Practice Address - Country:US
Practice Address - Phone:580-228-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1804225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant