Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225000000X | Orthotic Fitter | C22172 | AR |
Y | 225100000X | Physical Therapist | PT 1781 | AR |
NPI | 1609847847 |
---|---|
Provider Name | Barron Tracy South |
First Address | Fayetteville, AR 72701-7143 |
Second Address | Fayetteville, AR 72701-7143 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2006 |
Last Update Date | 14/09/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
129332721 | (05) | AR |