Provider Demographics
NPI:1144567140
Name:YOUNG, TIM JOE (PTA)
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:JOE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34676 COOPER RD
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-9001
Mailing Address - Country:US
Mailing Address - Phone:918-413-1295
Mailing Address - Fax:
Practice Address - Street 1:8520 S 36TH TER
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8880
Practice Address - Country:US
Practice Address - Phone:479-410-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOKPTA763225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant