Individual
JORDAN GONZALES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC, LAT
Contact information
Practice address
603 N GRAND AVE, TAHLEQUAH, OK 74464-2302
(918) 444-3921
Mailing address
1249 S 103RD EAST AVE, TULSA, OK 74128-4631
(918) 859-9098
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
830
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
63572
NATIONAL ATHLETIC TRAINERS' ASSOCIATION
OK
01
—
830
OKLAHOMA STATE BOARD OF MEDICAL LICENSURE AND SUPERVISION
OK
Enumeration date
05/04/2015
Last updated
05/04/2015
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