Healthcare Provider Details

I. General information

NPI: 1356556955
Provider Name (Legal Business Name): RUSSELL ALLEN FANNING PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N. ARAPAHO
HYDRO OK
73048
US

IV. Provider business mailing address

421 N DANIEL ST
WEATHERFORD OK
73096-4415
US

V. Phone/Fax

Practice location:
  • Phone: 405-663-2335
  • Fax:
Mailing address:
  • Phone: 580-603-1744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number1498
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: