Provider Demographics
NPI:1750689923
Name:BROADAWAY, INA RAE (PTA)
Entity Type:Individual
Prefix:
First Name:INA
Middle Name:RAE
Last Name:BROADAWAY
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 1:1801 CHAMPLIN DR
Mailing Address - Street 2:APT. 1206
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-3965
Mailing Address - Country:US
Mailing Address - Phone:870-758-0154
Mailing Address - Fax:
Practice Address - Street 1:1801 CHAMPLIN DR
Practice Address - Street 2:APT. 1206
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-3965
Practice Address - Country:US
Practice Address - Phone:870-758-0154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 804225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148454721Medicaid