Provider Demographics
NPI:1194200675
Name:WADE, JOSH (PTA)
Entity Type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:WADE
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 1:318 N GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-3454
Mailing Address - Country:US
Mailing Address - Phone:479-806-8606
Mailing Address - Fax:
Practice Address - Street 1:318 N GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3454
Practice Address - Country:US
Practice Address - Phone:479-806-8606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3943225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty