Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA4343 | AR |
NPI | 1013493675 |
---|---|
Provider Name | Jeffrey Homstad |
First Address | Conway, AR 72034-6900 |
Second Address | Maumelle, AR 72113-6700 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2018 |
Last Update Date | 17/07/2018 |