Provider Demographics
NPI:1720207384
Name:COFFMAN, TARA DALIS (PT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:DALIS
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19826 E COUNTY ROAD 162
Mailing Address - Street 2:
Mailing Address - City:OLUSTEE
Mailing Address - State:OK
Mailing Address - Zip Code:73560-9009
Mailing Address - Country:US
Mailing Address - Phone:580-477-2398
Mailing Address - Fax:
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6141
Practice Address - Country:US
Practice Address - Phone:580-379-5000
Practice Address - Fax:580-379-5509
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT2452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200079640AMedicaid