Provider Demographics
NPI:1578943767
Name:COX, SHANE
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:COX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-3105
Mailing Address - Country:US
Mailing Address - Phone:918-696-6826
Mailing Address - Fax:918-516-0479
Practice Address - Street 1:13 S 2ND ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-3105
Practice Address - Country:US
Practice Address - Phone:918-696-6826
Practice Address - Fax:918-516-0479
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200556050Medicaid