Provider Demographics
NPI:1417409426
Name:SHANNON, TRISHA MAE (MED, LAT, ATC)
Entity type:Individual
Prefix:MS
First Name:TRISHA
Middle Name:MAE
Last Name:SHANNON
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74171-0003
Mailing Address - Country:US
Mailing Address - Phone:918-494-6806
Mailing Address - Fax:918-495-7919
Practice Address - Street 1:7777 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74171-0003
Practice Address - Country:US
Practice Address - Phone:918-494-6806
Practice Address - Fax:918-495-7919
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer