MEDICARE: LAWANNA GAGE

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	225700000X	Massage Therapist	172283	OK

General Provider Information

NPI Number	:	1083211742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWANNA GAGE

Provider Business Mailing Address
First Line	:	1937 TREAT DR
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-2574
Country	:	US
Telephone Number	:	405-496-2499
Fax Number	:

Provider Business Practice Location Address
First Line	:	7901 NE 10TH ST STE A209
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-3689
Country	:	US
Telephone Number	:	405-496-2499
Fax Number	:

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

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	10/06/2020

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Directions to “ LAWANNA GAGE ” Practice Location

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