Healthcare Provider Details

I. General information

NPI: 1316306772
Provider Name (Legal Business Name): TYAN RORABAUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2016
Last Update Date: 08/21/2022
Certification Date: 08/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 N KLEIN CIR
DERBY KS
67037-7011
US

IV. Provider business mailing address

1515 N ROCKWOOD BLVD
MULVANE KS
67110-1023
US

V. Phone/Fax

Practice location:
  • Phone: 316-719-2400
  • Fax:
Mailing address:
  • Phone: 316-209-2231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-02758
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: