MEDICARE: MR. JOHN MARK HEUSMAN MS, LAT, ATC, CSCS

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	174400000X	Specialist	AT-82	OK

General Provider Information

NPI Number	:	1104943547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN MARK HEUSMAN MS, LAT, ATC, CSCS

Provider Business Mailing Address
First Line	:	8320 NW 111TH TER
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-2100
Country	:	US
Telephone Number	:	405-818-7910
Fax Number	:

Provider Business Practice Location Address
First Line	:	6201 N SANTA FE AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-7538
Country	:	US
Telephone Number	:	405-272-5478
Fax Number	:

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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