Provider Demographics
NPI:1417520503
Name:GASPARD, BRANDI (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:GASPARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 DAVE WARD DR STE 103
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8679
Mailing Address - Country:US
Mailing Address - Phone:501-327-1730
Mailing Address - Fax:
Practice Address - Street 1:2425 DAVE WARD DR STE 103
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8679
Practice Address - Country:US
Practice Address - Phone:501-327-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
4591225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PTA4591OtherPHYSICAL THERAPIST ASSISTANT