Healthcare Provider Details

I. General information

NPI: 1528065158
Provider Name (Legal Business Name): JASON MICHAEL SNYDER RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 N 14TH ST STE 111
PONCA CITY OK
74601-1952
US

IV. Provider business mailing address

706 S 1ST ST
BLACKWELL OK
74631-3825
US

V. Phone/Fax

Practice location:
  • Phone: 580-765-0101
  • Fax: 580-765-3434
Mailing address:
  • Phone: 580-363-1111
  • Fax: 580-363-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2540
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: