Provider Demographics
NPI:1811443518
Name:VANTRUMP, MICHAEL DEAN (PTA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:VANTRUMP
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:DEAN
Other - Last Name:VAN TRUMP
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1409 HIGHWAY 62 65 N
Practice Address - Street 2:STE 4
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-1911
Practice Address - Country:US
Practice Address - Phone:870-704-4076
Practice Address - Fax:870-741-0089
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2390225200000X
MO2007019796225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant