Provider Demographics
NPI:1932749454
Name:ROBERSON, CAGNEY AUSTIN
Entity Type:Individual
Prefix:
First Name:CAGNEY
Middle Name:AUSTIN
Last Name:ROBERSON
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 1:1117 SEQUOYAH PL APT B
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5217
Mailing Address - Country:US
Mailing Address - Phone:918-344-1898
Mailing Address - Fax:
Practice Address - Street 1:100 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5207
Practice Address - Country:US
Practice Address - Phone:405-974-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAA7752255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer