Roger Olen Kollock Jr., ATC

Primary specialty

Athletic TrainerTaxonomy code 2255A2300X

License

AT1084 Issued in OK

Practice address

2405 S 14TH St
Broken Arrow, OK 74012-7263

Phone

(423) 943-1528

NPI assigned

May 5, 2006

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• East Tennessee State University

  • Primary Care Nurse Practitioner
  • Gray, TN
  • NPI 1033344007
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146787200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1577404800000",
    "number": "1922057264",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2405 S 14TH ST",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740127263",
            "telephone_number": "423-943-1528"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2405 S 14TH ST",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740127263",
            "telephone_number": "423-943-1528"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1440 Suncrest Dr",
            "address_purpose": "LOCATION",
            "city": "Gray",
            "state": "TN",
            "postal_code": "376154118",
            "country_code": "US",
            "telephone_number": "423-477-1600",
            "fax_number": "423-477-1625",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KOLLOCK",
        "first_name": "ROGER",
        "middle_name": "OLEN",
        "name_prefix": "Mr.",
        "name_suffix": "Jr.",
        "credential": "ATC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-05-05",
        "last_updated": "2019-12-27",
        "certification_date": "2019-12-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2255A2300X",
            "taxonomy_group": "",
            "desc": "Specialist/Technologist, Athletic Trainer",
            "state": "OK",
            "license": "AT1084",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Deborah Knight
• Summer Knight
• Amanda Nicole Knittel
• Roderick Vincent Knowles Jr., BHRS/CASE MANAGER
• Sarah Michele Koehling
• Mercades Kolosha, RDMS
• Douglas Scott Kooken II, DDS
• Nidhi Koul, M.D.
• Jade Elyssa Kraf-Brown, RN
• Zonzurea Kressel, MBS, LPC-SUPERVISOR

• All providers in Broken Arrow, OK
• Athletic Trainer in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.