MEDICARE: ALLISON MARIE RUSSELL ATC

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	171W00000X	Contractor	0417	OK
2	2255A2300X	Athletic Trainer	417	OK
3	2255A2300X	Athletic Trainer	6596	TX

General Provider Information

NPI Number	:	1053695742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLISON MARIE RUSSELL ATC

Provider Business Mailing Address
First Line	:	10749 E 29TH PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-7805
Country	:	US
Telephone Number	:	918-810-6293
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 E BORDER ST STE 250
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76010-7445
Country	:	US
Telephone Number	:	918-810-6293
Fax Number	:

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

Provider Enumeration Date	:	09/29/2011
Last Update Date	:	05/10/2018

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Directions to “ ALLISON MARIE RUSSELL ATC” Practice Location

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