Provider Demographics
NPI:1649621012
Name:TIARKS, NATHAN (PT)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:TIARKS
Suffix:
Gender:M
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:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-498-6700
Mailing Address - Fax:479-968-4331
Practice Address - Street 1:51ST MEDICAL GROUP UNIT 2060
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96278-2060
Practice Address - Country:US
Practice Address - Phone:505-784-2157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-28
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT4076225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist