Provider Demographics
NPI:1104030675
Name:SIMMONS, SHAWN PATRICK (PT)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:PATRICK
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:842 LITTLE RIVER 17
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-9455
Mailing Address - Country:US
Mailing Address - Phone:870-898-2583
Mailing Address - Fax:
Practice Address - Street 1:451 W LOCKE ST
Practice Address - Street 2:
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822-3325
Practice Address - Country:US
Practice Address - Phone:870-898-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 2173225100000X
TX1096923225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145189721Medicaid