Provider Demographics
NPI:1336368018
Name:TANNER, LARRY SIDNEY (RPT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:SIDNEY
Last Name:TANNER
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8809 S SOONER RD
Mailing Address - Street 2:STE E
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-6605
Mailing Address - Country:US
Mailing Address - Phone:405-919-0135
Mailing Address - Fax:405-273-7084
Practice Address - Street 1:1519 N OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-3848
Practice Address - Country:US
Practice Address - Phone:405-919-0135
Practice Address - Fax:405-273-7084
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1807225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist