Healthcare Provider Details

I. General information

NPI: 1720470511
Provider Name (Legal Business Name): TYLER WILLIAM OBENRADER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22685 ROUTE 68
CLARION PA
16214-4019
US

IV. Provider business mailing address

PO BOX 248
SENECA PA
16346-0248
US

V. Phone/Fax

Practice location:
  • Phone: 814-223-4090
  • Fax: 814-223-4092
Mailing address:
  • Phone: 814-670-0534
  • Fax: 814-670-0653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT023789
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1030153130002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: