Provider Demographics
NPI:1033936109
Name:MEDLYN, JAMES ROBERT (PTA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:MEDLYN
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 1:3302 S 97TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-5712
Mailing Address - Country:US
Mailing Address - Phone:479-459-7077
Mailing Address - Fax:
Practice Address - Street 1:117 NORTHRIDGE DR E STE C
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-5183
Practice Address - Country:US
Practice Address - Phone:479-474-4892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA1787225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant