Healthcare Provider Details

I. General information

NPI: 1982685608
Provider Name (Legal Business Name): BRANDON SCOTT HETZLER ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1323 W 6TH AVE
STILLWATER OK
74074-4306
US

IV. Provider business mailing address

1323 W 6TH AVE
STILLWATER OK
74074-4306
US

V. Phone/Fax

Practice location:
  • Phone: 405-742-5996
  • Fax:
Mailing address:
  • Phone: 405-742-5996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT264
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: