Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2204 | AR |
NPI | 1013223957 |
---|---|
Provider Name | Bruce Brian |
First Address | Clarksville, AR 72830-2019 |
Second Address | Clarksville, AR 72830-2019 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2010 |
Last Update Date | 14/12/2011 |