MEDICARE: TRUDY CHRISTINE GATEWOOD PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA2542	AR

General Provider Information

NPI Number	:	1588944599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRUDY CHRISTINE GATEWOOD PTA

Provider Business Mailing Address
First Line	:	927 E PHILPOT RD
Second Line	:
City	:	OZARK
State	:	AR
Zip	:	72949-9611
Country	:	US
Telephone Number	:	479-209-0995
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 E MAIN ST
Second Line	:
City	:	CHARLESTON
State	:	AR
Zip	:	72933-9254
Country	:	US
Telephone Number	:	479-209-0995
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2011
Last Update Date	:	10/09/2023

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