Provider Demographics
NPI:1386070530
Name:ROLETTE, TYLER AUSTIN (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:AUSTIN
Last Name:ROLETTE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356110 E 930 RD
Mailing Address - Street 2:
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-5184
Mailing Address - Country:US
Mailing Address - Phone:918-968-9531
Mailing Address - Fax:918-968-1532
Practice Address - Street 1:356110 E 930 RD
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-5184
Practice Address - Country:US
Practice Address - Phone:918-968-9531
Practice Address - Fax:918-968-1532
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist