Healthcare Provider Details

I. General information

NPI: 1194925115
Provider Name (Legal Business Name): BRYAN LYNN GREEN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 04/06/2024
Certification Date: 04/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 34TH AVE SW
NORMAN OK
73072-4843
US

IV. Provider business mailing address

231 34TH AVE SW
NORMAN OK
73072-4843
US

V. Phone/Fax

Practice location:
  • Phone: 405-593-8353
  • Fax: 888-558-6690
Mailing address:
  • Phone: 512-924-8890
  • Fax: 888-558-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number4093
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number4093
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number4093
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4093
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: