MEDICARE: TARAH TUSTIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	3469	OK

General Provider Information

NPI Number	:	1063258291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARAH TUSTIN

Provider Business Mailing Address
First Line	:	28291 OLD TARBY RD
Second Line	:
City	:	POTEAU
State	:	OK
Zip	:	74953-7165
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11055 S MEMORIAL DR
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-7362
Country	:	US
Telephone Number	:	918-369-3350
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2024
Last Update Date	:	07/08/2024

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Directions to “ TARAH TUSTIN ” Practice Location

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