Provider Demographics
NPI:1912471244
Name:HADERER, TYLER KINCAID (DC)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:KINCAID
Last Name:HADERER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 W 33RD ST STE 130
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3824
Mailing Address - Country:US
Mailing Address - Phone:405-341-9885
Mailing Address - Fax:
Practice Address - Street 1:1751 W 33RD ST STE 130
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3824
Practice Address - Country:US
Practice Address - Phone:405-341-9885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4314111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty