Provider Demographics
NPI:1861456014
Name:CAANG, MYRA HIZOLA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:HIZOLA
Last Name:CAANG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WAVERLY CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9490
Mailing Address - Country:US
Mailing Address - Phone:870-740-2175
Mailing Address - Fax:
Practice Address - Street 1:300 WAVERLY CV
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9490
Practice Address - Country:US
Practice Address - Phone:870-740-2175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W948OtherBCBS INDIV. PROVIDER #
AR146510721Medicaid