Healthcare Provider Details

I. General information

NPI: 1154708626
Provider Name (Legal Business Name): JORDAN GONZALES ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 N GRAND AVE
TAHLEQUAH OK
74464-2302
US

IV. Provider business mailing address

1249 S 103RD EAST AVE
TULSA OK
74128-4631
US

V. Phone/Fax

Practice location:
  • Phone: 918-444-3921
  • Fax:
Mailing address:
  • Phone: 918-859-9098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number830
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier63572
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerNATIONAL ATHLETIC TRAINERS' ASSOCIATION
# 2
Identifier830
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: