Provider Demographics
NPI:1346461712
Name:RIDER, VERNON TYRONE (PT)
Entity Type:Individual
Prefix:MR
First Name:VERNON
Middle Name:TYRONE
Last Name:RIDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 NW EXPRESSWAY ST APT 212
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5133
Mailing Address - Country:US
Mailing Address - Phone:405-773-0806
Mailing Address - Fax:
Practice Address - Street 1:9400 SAINT ANN DR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-6400
Practice Address - Country:US
Practice Address - Phone:405-722-5103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist