Provider Demographics
NPI:1720289747
Name:TAYLOR, TRAVIS DEAN (RPT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DEAN
Last Name:TAYLOR
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 1:8820 NW 116TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2221
Mailing Address - Country:US
Mailing Address - Phone:405-749-8131
Mailing Address - Fax:405-752-2969
Practice Address - Street 1:1400 NW 122ND ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-8027
Practice Address - Country:US
Practice Address - Phone:405-749-8131
Practice Address - Fax:405-752-2969
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2655OtherPHYSICAL THERAPY LICENSE