Provider Demographics
NPI:1801986740
Name:LANDRUM, CORD TANNER (DC, PA-C)
Entity type:Individual
Prefix:DR
First Name:CORD
Middle Name:TANNER
Last Name:LANDRUM
Suffix:
Gender:M
Credentials:DC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:580-925-9149
Practice Address - Street 1:905 COLONY DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2329
Practice Address - Country:US
Practice Address - Phone:580-436-5111
Practice Address - Fax:580-436-1159
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3744111N00000X
OK3003363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3003OtherOKLAHOMA BOARD OF MEDICAL LICENSURE