MEDICARE: MR. JASON MICHAEL SNYDER RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT2540	OK

General Provider Information

NPI Number	:	1528065158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON MICHAEL SNYDER RPT

Provider Business Mailing Address
First Line	:	706 S 1ST ST
Second Line	:
City	:	BLACKWELL
State	:	OK
Zip	:	74631-3825
Country	:	US
Telephone Number	:	580-363-1111
Fax Number	:	580-363-1116

Provider Business Practice Location Address
First Line	:	2005 N 14TH ST
Second Line	:	STE 111
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1952
Country	:	US
Telephone Number	:	580-765-0101
Fax Number	:	580-765-3434

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	07/08/2007

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