Provider Demographics
NPI:1043405475
Name:SHAWNEE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SHAWNEE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-878-8686
Mailing Address - Street 1:909 N KICKAPOO AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-5729
Mailing Address - Country:US
Mailing Address - Phone:405-878-8686
Mailing Address - Fax:
Practice Address - Street 1:909 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-5729
Practice Address - Country:US
Practice Address - Phone:405-878-8686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1924261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy