Provider Demographics
NPI:1689798191
Name:IRVIN, JOE (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:
Last Name:IRVIN
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 1:1441 HIGHWAY 62 412
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72542-9497
Mailing Address - Country:US
Mailing Address - Phone:870-856-9675
Mailing Address - Fax:870-856-9679
Practice Address - Street 1:1441 HIGHWAY 62 412
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9497
Practice Address - Country:US
Practice Address - Phone:870-856-9675
Practice Address - Fax:870-856-9679
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPTA 2000OtherLICENSE