Provider Demographics
NPI:1225016728
Name:POMEROY, TYLER EMERSON (MSPT, OCS, FAAOMPT)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:EMERSON
Last Name:POMEROY
Suffix:
Gender:M
Credentials:MSPT, OCS, FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 FRETZ DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-5782
Mailing Address - Country:US
Mailing Address - Phone:405-285-8477
Mailing Address - Fax:405-285-8499
Practice Address - Street 1:1410 FRETZ DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-5782
Practice Address - Country:US
Practice Address - Phone:405-285-8477
Practice Address - Fax:405-285-8499
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT 3112225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200054310AMedicaid
OK$$$$$$$$$002OtherBCBS OK
OK200054310AMedicaid