Provider Demographics
NPI:1730685314
Name:MILLWEE, JOHNATHON DAVID (ATC)
Entity type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:DAVID
Last Name:MILLWEE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7841 S UNION AVE APT 2203
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-2766
Mailing Address - Country:US
Mailing Address - Phone:580-302-1121
Mailing Address - Fax:
Practice Address - Street 1:4802 S 109TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146
Practice Address - Country:US
Practice Address - Phone:580-302-1121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer