Provider Demographics
NPI:1467679449
Name:SAMPLE, DENNIS ALAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:ALAN
Last Name:SAMPLE
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 1:321 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IN
Mailing Address - Zip Code:46938-1618
Mailing Address - Country:US
Mailing Address - Phone:765-618-8047
Mailing Address - Fax:765-674-9491
Practice Address - Street 1:321 E 11TH ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:IN
Practice Address - Zip Code:46938-1618
Practice Address - Country:US
Practice Address - Phone:765-618-8047
Practice Address - Fax:765-674-9491
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002277A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN470OtherPHYSICAL THERAPIST ASST.