Provider Demographics
NPI:1720470511
Name:OBENRADER, TYLER WILLIAM (DPT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:WILLIAM
Last Name:OBENRADER
Suffix:
Gender:M
Credentials:DPT
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 248
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:PA
Mailing Address - Zip Code:16346-0248
Mailing Address - Country:US
Mailing Address - Phone:814-670-0534
Mailing Address - Fax:814-670-0653
Practice Address - Street 1:22685 ROUTE 68
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214-4019
Practice Address - Country:US
Practice Address - Phone:814-223-4090
Practice Address - Fax:814-223-4092
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT023789225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030153130002Medicaid