Provider Demographics
NPI:1508231168
Name:COLVIN, JOHN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:COLVIN
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 1:408 SIMSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:EVENING SHADE
Mailing Address - State:AR
Mailing Address - Zip Code:72532-9458
Mailing Address - Country:US
Mailing Address - Phone:870-994-7778
Mailing Address - Fax:
Practice Address - Street 1:75 HIGHWAY 62 412 STE A
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513-9629
Practice Address - Country:US
Practice Address - Phone:870-994-7778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2746225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant