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General NPI Number Information
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NPI Number | 1013404342
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Entity Type | Individual
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Provider Name | NICHOLAS RYAN BEASLEY ATC, CSCS, CES
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Gender | Male
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Dates
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Enumeration Date | 04/23/2018
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Last Update Date | 04/23/2018
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Provider Practice Location Address
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Address Line | 3701 S I 35 SERVICE RD
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City | MOORE
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State | OK
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Zip | 73160-3183
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Country | US
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Telephone | 405-912-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 3720 S TELEPHONE RD
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City | MOORE
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State | OK
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Zip | 73160-2914
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Country | US
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Telephone | 303-396-7205
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000017666
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License Number State | CO
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