MEDICARE: MRS. SHANON M FUNKHOUSER COTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	810	OK

General Provider Information

NPI Number	:	1053513606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANON M FUNKHOUSER COTA

Provider Business Mailing Address
First Line	:	10700 S MAY AVE APT 126
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73170-2576
Country	:	US
Telephone Number	:	405-885-9141
Fax Number	:	580-323-4509

Provider Business Practice Location Address
First Line	:	9070 HARMONY DR STE A
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-6257
Country	:	US
Telephone Number	:	405-455-5582
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/12/2021

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