Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | PT2259 | AR |
NPI | 1083649917 |
---|---|
Provider Name | Mrs. Samantha Cavagnaro |
First Address | Bauxite, AR 72011-8932 |
Second Address | Ward, AR 72176 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5U633 | BLUE CROSS BLUE SHIELD (01) | AR |