Provider Demographics
NPI:1821722174
Name:TIPPECONNIC, TROY WILLIAM
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:WILLIAM
Last Name:TIPPECONNIC
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:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-0746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20208 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-9123
Practice Address - Country:US
Practice Address - Phone:405-454-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist