Healthcare Provider Details

I. General information

NPI: 1831577113
Provider Name (Legal Business Name): MATTHEW BRANNON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 2ND AVE SW
MIAMI OK
74354-6743
US

IV. Provider business mailing address

310 2ND AVE SW
MIAMI OK
74354-6743
US

V. Phone/Fax

Practice location:
  • Phone: 918-540-7736
  • Fax: 918-540-7739
Mailing address:
  • Phone: 918-540-7736
  • Fax: 918-540-7739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number245
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: