Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 4350 | AR |
NPI | 1013492230 |
---|---|
Provider Name | Ms. Ellissa Lauren Mason |
First Address | Beebe, AR 72012-9726 |
Second Address | Springfield, TN 37172-4801 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/10/2018 |
Last Update Date | 03/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4350 | PHYSICAL THERAPIST ASSISTANT (01) | AR |