Provider Demographics
NPI:1356556955
Name:FANNING, RUSSELL ALLEN (PTA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ALLEN
Last Name:FANNING
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 N DANIEL ST
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-4415
Mailing Address - Country:US
Mailing Address - Phone:580-603-1744
Mailing Address - Fax:
Practice Address - Street 1:800 N. ARAPAHO
Practice Address - Street 2:
Practice Address - City:HYDRO
Practice Address - State:OK
Practice Address - Zip Code:73048
Practice Address - Country:US
Practice Address - Phone:405-663-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1498225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant