Healthcare Provider Details

I. General information

NPI: 1619446747
Provider Name (Legal Business Name): TRENTON MICHAEL ROYSE LAT, ATC, CES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 S LEWIS AVE
TULSA OK
74171-0003
US

IV. Provider business mailing address

7821 E 97TH PL APT 12306
TULSA OK
74133-6957
US

V. Phone/Fax

Practice location:
  • Phone: 918-495-7745
  • Fax:
Mailing address:
  • Phone: 402-417-3326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number1010
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: