Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA 1550 | AR |
NPI | 1013286053 |
---|---|
Provider Name | Mr. Michael Lee David |
First Address | Pea Ridge, AR 72751-2919 |
Second Address | Pea Ridge, AR 72751-2919 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2011 |
Last Update Date | 20/12/2011 |