Basic Information
| Provider Information | |||||||||
| NPI: | 1144567140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | TIM | ||||||||
| MiddleName: | JOE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34676 COOPER RD | ||||||||
| Address2: | |||||||||
| City: | POTEAU | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749539001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184131295 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8520 S 36TH TER | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729088880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794101740 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2013 | ||||||||
| LastUpdateDate: | 01/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | OKPTA763 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.