Provider Demographics
NPI:1942573266
Name:PASSMORE, BRET TRAPPER (PTA)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:TRAPPER
Last Name:PASSMORE
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 1:719 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-9607
Mailing Address - Country:US
Mailing Address - Phone:479-495-6252
Mailing Address - Fax:
Practice Address - Street 1:719 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-9607
Practice Address - Country:US
Practice Address - Phone:479-495-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2517225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR189735721Medicaid