Provider Demographics
NPI:1225358021
Name:GANN, DARRELL R (PTA)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:R
Last Name:GANN
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 1:6040 BEAVER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9558
Mailing Address - Country:US
Mailing Address - Phone:870-219-2107
Mailing Address - Fax:
Practice Address - Street 1:6040 BEAVER CREEK
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404
Practice Address - Country:US
Practice Address - Phone:870-219-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2401225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant