Provider Demographics
NPI:1154679736
Name:CUNNINGHAM, DOUGLAS WADE
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WADE
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PEA RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72751-2751
Mailing Address - Country:US
Mailing Address - Phone:479-521-8326
Mailing Address - Fax:479-521-5439
Practice Address - Street 1:2474 E JOYCE BLVD
Practice Address - Street 2:STE. 2
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4519
Practice Address - Country:US
Practice Address - Phone:479-521-8326
Practice Address - Fax:479-521-5439
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2668225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant