Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | PTA1436 | AR |
NPI | 1003952904 |
---|---|
Provider Name | Teresa Travis |
First Address | Wynne, AR 72396-4032 |
Second Address | Pine Bluff, AR 71603-5008 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/01/2007 |
Last Update Date | 09/07/2007 |