Individual
SHANE STOVALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RPT
Contact information
Practice address
1405 4TH AVE NW # 296, ARDMORE, OK 73401-2708
(580) 795-4768
Mailing address
1405 4TH AVE NW # 296, ARDMORE, OK 73401-2708
(580) 795-4768
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
2905
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100833900A
—
OK
05
—
100833900C
—
OK
05
—
1743403 01
—
TX
Enumeration date
10/02/2006
Last updated
09/22/2009
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