Basic Information
| Provider Information | |||||||||
| NPI: | 1831577113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANNON | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 2ND AVE SW | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743546743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185407736 | ||||||||
| FaxNumber: | 9185407739 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 2ND AVE SW | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743546743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185407736 | ||||||||
| FaxNumber: | 9185407739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2015 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 245 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.