Healthcare Provider Details

I. General information

NPI: 1538784277
Provider Name (Legal Business Name): MATTISON MARY NICOLE LAGERS AT, PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MATTISON MARY NICOLE WEBER AT, PTA

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2488 E 81ST ST STE 290
TULSA OK
74137-4265
US

IV. Provider business mailing address

2488 E 81ST ST STE 290
TULSA OK
74137-4265
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-2665
  • Fax: 918-927-3193
Mailing address:
  • Phone: 918-927-3226
  • Fax: 918-927-3193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2836
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number883
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: