Provider Demographics
NPI:1366649709
Name:TANKERSLEY, GREGORY PAUL
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:PAUL
Last Name:TANKERSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:GREG
Other - Middle Name:PAUL
Other - Last Name:TANKERSLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:224 SANTA FE DR
Mailing Address - Street 2:400
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-6574
Mailing Address - Country:US
Mailing Address - Phone:817-594-7697
Mailing Address - Fax:
Practice Address - Street 1:224 SANTA FE DR
Practice Address - Street 2:400
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-6574
Practice Address - Country:US
Practice Address - Phone:817-594-7697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4115111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752611507OtherEIN
TX752611507OtherEIN