Provider Demographics
NPI:1497820252
Name:WALLACE, RANDALL ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:ALLEN
Last Name:WALLACE
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 1:18305 ENGLISH OAK LN
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-4051
Mailing Address - Country:US
Mailing Address - Phone:405-216-8731
Mailing Address - Fax:
Practice Address - Street 1:409 E. CALIFORNIA AVE.
Practice Address - Street 2:
Practice Address - City:OAKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-879-6766
Practice Address - Fax:405-879-3493
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2855225100000X, 2251E1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics