Provider Demographics
NPI:1538283742
Name:PARKS, LANE STEWART (ATC)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:STEWART
Last Name:PARKS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-2736
Mailing Address - Country:US
Mailing Address - Phone:405-330-7901
Mailing Address - Fax:
Practice Address - Street 1:413 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-2736
Practice Address - Country:US
Practice Address - Phone:405-330-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAT1042255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer