Individual
SHANE MATTHEW BJORNBERG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
11049 N 147TH EAST AVE, OWASSO, OK 74055-6263
(918) 978-6274
Mailing address
11049 N 147TH EAST AVE, OWASSO, OK 74055-6263
(918) 978-6274
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
3967
OK
2251X0800X
Orthopedic Physical Therapist
Primary
PT 3550
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200034500A
—
OK
05
—
200034500B
—
OK
05
—
200034500C
—
OK
05
—
200034500D
—
OK
05
—
200034500E
—
OK
05
—
200034500F
—
OK
05
—
200034500G
—
OK
05
—
200034500H
—
OK
05
—
200034500I
—
OK
05
—
200100580A
—
OK
01
—
6935423
CIGNA
OK
01
—
7784889
AETNA
OK
Enumeration date
12/14/2006
Last updated
03/28/2013
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