Provider Demographics
NPI:1497231302
Name:BRYANT, TERA SHAWN
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:SHAWN
Last Name:BRYANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 W 17TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4654
Mailing Address - Country:US
Mailing Address - Phone:918-378-5404
Mailing Address - Fax:
Practice Address - Street 1:252 W 17TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4654
Practice Address - Country:US
Practice Address - Phone:918-378-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist