Provider Demographics
NPI:1417215203
Name:PADDOCK, MICHAEL BRYAN (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRYAN
Last Name:PADDOCK
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 1:92 QUAPAW TRL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-8991
Mailing Address - Country:US
Mailing Address - Phone:501-626-5825
Mailing Address - Fax:
Practice Address - Street 1:92 QUAPAW TRL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-8991
Practice Address - Country:US
Practice Address - Phone:501-626-5825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PTA1472225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant