Provider Demographics
NPI:1346302817
Name:BJORNBERG, SHANE MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MATTHEW
Last Name:BJORNBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11049 N 147TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-6263
Mailing Address - Country:US
Mailing Address - Phone:918-978-6274
Mailing Address - Fax:
Practice Address - Street 1:11049 N 147TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6263
Practice Address - Country:US
Practice Address - Phone:918-978-6274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3967225100000X
ARPT 35502251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200100580AMedicaid
OK200034500GMedicaid
OK200034500IMedicaid
OK200034500AMedicaid
OK200034500DMedicaid
OK200034500HMedicaid
OK7784889OtherAETNA
OK200034500FMedicaid
OK200034500CMedicaid
OK200034500BMedicaid
OK200034500EMedicaid
OK6935423OtherCIGNA
OK200034500IMedicaid