Provider Demographics
NPI:1538784277
Name:LAGERS, MATTISON MARY NICOLE (AT, PTA)
Entity type:Individual
Prefix:
First Name:MATTISON
Middle Name:MARY NICOLE
Last Name:LAGERS
Suffix:
Gender:F
Credentials:AT, PTA
Other - Prefix:
Other - First Name:MATTISON
Other - Middle Name:MARY NICOLE
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AT, PTA
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-927-3226
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2488 E 81ST ST STE 290
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4265
Practice Address - Country:US
Practice Address - Phone:918-494-2665
Practice Address - Fax:918-927-3193
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2836225200000X
OK8832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant