Healthcare Provider Details

I. General information

NPI: 1942295316
Provider Name (Legal Business Name): MATTHEW SCOTT O'BRIEN PHD, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 GALLAGHER IBA HALL
STILLWATER OK
74078-0001
US

IV. Provider business mailing address

3108 W 30TH AVE
STILLWATER OK
74074-2215
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-9439
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-302
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: