Provider Demographics
NPI:1205507399
Name:GANNAWAY, SAMANTHA (PTA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GANNAWAY
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 1:101 SAMMY FARRELL RD
Mailing Address - Street 2:
Mailing Address - City:MC GEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-9770
Mailing Address - Country:US
Mailing Address - Phone:870-877-1675
Mailing Address - Fax:
Practice Address - Street 1:101 SAMMY FARRELL RD
Practice Address - Street 2:
Practice Address - City:MC GEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-9770
Practice Address - Country:US
Practice Address - Phone:870-877-1675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4663225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4663Medicaid