Provider Demographics
NPI:1962617738
Name:WHYBURN, TRACY G
Entity type:Individual
Prefix:MR
First Name:TRACY
Middle Name:G
Last Name:WHYBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6332 E 98TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-5022
Mailing Address - Country:US
Mailing Address - Phone:918-625-6377
Mailing Address - Fax:
Practice Address - Street 1:6332 E 98TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-5022
Practice Address - Country:US
Practice Address - Phone:918-625-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle