Provider Demographics
NPI:1386619856
Name:REGGIO, TAMMIE D (PA)
Entity type:Individual
Prefix:
First Name:TAMMIE
Middle Name:D
Last Name:REGGIO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:D
Other - Last Name:MANESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4300 CARAVEL DR APT 1115
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-3782
Mailing Address - Country:US
Mailing Address - Phone:580-716-0245
Mailing Address - Fax:
Practice Address - Street 1:14101 N EASTERN AVE STE B
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5860
Practice Address - Country:US
Practice Address - Phone:888-245-9806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK981207P00000X, 363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100227880AMedicaid
S84696Medicare UPIN
OK100227880AMedicaid