Provider Demographics
NPI:1538104369
Name:CONLY, BRYCE WADE (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRYCE
Middle Name:WADE
Last Name:CONLY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 W LOWRY RD
Mailing Address - Street 2:STE #101
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-2106
Mailing Address - Country:US
Mailing Address - Phone:918-697-8945
Mailing Address - Fax:918-341-3779
Practice Address - Street 1:705 W LOWRY RD
Practice Address - Street 2:STE #101
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-2106
Practice Address - Country:US
Practice Address - Phone:918-697-8945
Practice Address - Fax:918-341-3779
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2014-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2000063070AMedicaid
OK243532001Medicare ID - Type Unspecified