Provider Demographics
NPI:1427407378
Name:RUNYAN, PRESTON
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:
Last Name:RUNYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 MERCHANT DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6470
Mailing Address - Country:US
Mailing Address - Phone:405-809-8713
Mailing Address - Fax:405-573-6768
Practice Address - Street 1:14890 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-3515
Practice Address - Country:US
Practice Address - Phone:405-390-1731
Practice Address - Fax:405-390-1981
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5146225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist