Provider Demographics
NPI:1134350416
Name:CORTES TAN, SHIRLEY (PT)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:CORTES TAN
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 1:451 W LOCKE ST
Mailing Address - Street 2:
Mailing Address - City:ASHDOWN
Mailing Address - State:AR
Mailing Address - Zip Code:71822-3325
Mailing Address - Country:US
Mailing Address - Phone:870-898-4115
Mailing Address - Fax:870-898-4130
Practice Address - Street 1:451 W LOCKE ST
Practice Address - Street 2:
Practice Address - City:ASHDOWN
Practice Address - State:AR
Practice Address - Zip Code:71822-3325
Practice Address - Country:US
Practice Address - Phone:870-898-4115
Practice Address - Fax:870-898-4130
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT 1686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145189721Medicaid