Healthcare Provider Details

I. General information

NPI: 1114749314
Provider Name (Legal Business Name): TYLER CONLEY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2024
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W MAIN ST
MARLOW OK
73055-2437
US

IV. Provider business mailing address

1186 COUNTY ROAD 1560
RUSH SPRINGS OK
73082-3038
US

V. Phone/Fax

Practice location:
  • Phone: 580-721-7100
  • Fax:
Mailing address:
  • Phone: 580-861-2504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3355
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: