MEDICARE: SHANNON LANCE ATC

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	2255A2300X	Athletic Trainer	775	OK

General Provider Information

NPI Number	:	1982098919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON LANCE ATC

Provider Business Mailing Address
First Line	:	1341 E 146TH PL S
Second Line	:
City	:	GLENPOOL
State	:	OK
Zip	:	74033-3714
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 N MINGO RD
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74116-5000
Country	:	US
Telephone Number	:	918-292-3397
Fax Number	:

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

Provider Enumeration Date	:	03/27/2015
Last Update Date	:	03/27/2015

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Directions to “ SHANNON LANCE ATC” Practice Location

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