Provider Demographics
NPI:1295190593
Name:WANTLAND, ROGER DALE (RPT)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:DALE
Last Name:WANTLAND
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4350 WILL ROGERS PKWY STE 600
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73108-1808
Mailing Address - Country:US
Mailing Address - Phone:405-948-2813
Mailing Address - Fax:405-948-2807
Practice Address - Street 1:1901 PARKWAY DRIVE
Practice Address - Street 2:
Practice Address - City:ELRENO
Practice Address - State:OK
Practice Address - Zip Code:73036
Practice Address - Country:US
Practice Address - Phone:405-262-2608
Practice Address - Fax:405-262-2558
Is Sole Proprietor?:No
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1850225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist